| Abstract|| |
The pelvic cavity is a basin-like space in the lowermost part of the abdomen where various neoplastic and non neoplastic lesions can occur involving its contents. When the nature of lesions are not clearly gynecological, patients are managed by surgeons. Our study aims to asses the clinicopathologic analysis of neoplastic lesions of the pelvic cavity managed by surgeons particularly over a period of 2 years. Out of 162 total lesions, 102 cases were non neoplastic, such as appendicular lump, Tubo-ovarian (TO) mass, hematoma and 60 cases were neoplastic. Among the 60 cases of neoplastic lesions, 40 cases were benign comprised of twisted ovarian cyst, broad-ligament fibroid, and neurofibroma and 20 cases were malignant comprised of colorectal carcinoma, ovarian carcinoma, liposarcoma, Primitive nurectodermal tumor (PNET), seminoma, and lymphnode metastasis. The lesions in such closed, difficult to approach areas throws clinicians into a diagnostic dilemma during both the preoperative and intraoperative period. Even pathologists cannot ascertain some diagnosis without the help of immunohistochemistry. So, to adopt early and concise management protocol, there should be more such studies in different institutions that are currently lacking in world literature.
Keywords: Clinicopathologic study, neoplastic lesions, pelvic cavity
|How to cite this article:|
Bhattacharyya NK, Mallick MG, Roy H, Das MK, Gautam D. Clinicopathologic study of pelvic lesions managed by surgeons in a medical college in Kolkata in the last 2 years. Indian J Pathol Microbiol 2008;51:500-3
|How to cite this URL:|
Bhattacharyya NK, Mallick MG, Roy H, Das MK, Gautam D. Clinicopathologic study of pelvic lesions managed by surgeons in a medical college in Kolkata in the last 2 years. Indian J Pathol Microbiol [serial online] 2008 [cited 2020 Apr 7];51:500-3. Available from: http://www.ijpmonline.org/text.asp?2008/51/4/500/43740
| Introduction|| |
The pelvic cavity is defined as the basin-like space in the lowermost part of the abdominal cavity and is bound by bony pelvis. The organs in the pelvic cavity in both genders are sigmoid colon, rectum, anal canal, rarely appendix, a few loops of small intestine, and urinary bladder with part of ureters. In addition, the prostate, seminal vesicles, and vas deferens exist in males. For females, there are two ovaries, a uterus with both Fallopian tube More Detailss, broad ligaments, and round ligaments. Rarely, dropped kidney and undescended testes may be present in the pelvic cavity. In both gebders, there are muscles of pelvic floor, fat, areolar tissues, nerves, blood vessels, and lymph nodes. Therfore, any inflammation or neoplastic lesion of any of these contents may give rise to various symptoms and signs of which most cases are ultimately referred to the surgical department either as an emergency patient or to the out-patient department. Common clinical manifestations are either of the following: bleeding per rectum, hematuria, lump in the lower abdomen, heaviness or pain in the perineum, dysuria, urinary retention, absolute constipation and a few non specific features like anemia, ascites, or edema in one or both legs. Modern radiologic assessments can accurately diagnose most of the pelvic lesions with their nature and extent of involvement. The pelvic lesions of internal genitals in females that are obvious clinically and radiologically are usually managed by gynecologists. Hence, surgeons have the chance to manage those cases related to intestines, urinary tract, prostate, soft-tissue origin, and female genitals without obvious features.
In our study, we have also analyzed the clinicopathologic aspect of those pelvic lesions that had been referred by surgeons.
Our aim and objectives of this study are to see the distribution of pelvic lesions particularly of different types of neoplastic lesions in different age and sexes. It also includes the identification of those cases which are diagnostic dilemmas to adopt early management protocol.
| Materials and Methods|| |
This is a retrospective study. A total of 162 cases of pelvic lesions referred by the Surgery department of the Medical College in Kolkata between April 2005 and March 2007 have been chosen for our study. Of these cases, 102 were inflammatory or non neoplastic in origin and these cases were not included in our specific analysis group. We have given importance to the analysis of neoplastic cases that have been proven histopathologically. Among the non neoplastic lesions, important cases were patients with an appendicular lump, diverticulosis with an inflammation of the intestines, volvulus, traumatic hematoma, a dropped kidney with hydronephrotic changes, a pelvic cold abscess, and a tubo-ovarian mass.
The diagnostic work-up of the lesions that were attended to in an emergency situation could not be performed properly as per protocol because of a lack of time, but this was done properly in cases that were attended to by the surgical out-patient department. The diagnostic work-up included full clinical details, a routine blood examination along with biochemistry and tumor marker estimations, a routine urine examination along with culture, a routine stool examination with occult blood test, a radiological examination (either an ultrasonography [USG], a computed tomography [CT] scan, or a magnetic imaging resonance [MRI]), laparotomy findings, and a histopathological examination of specimens along with the immunohistochemistry of cases of diagnostic problems.
| Results|| |
The distribution of non neoplastic and neoplastic lesions in our study is shown in [Table 1]. Among the 60 cases of neoplastic lesions, 40 cases were benign and 20 cases were malignant in nature. The benign cases include twisted ovarian cyst (19), broad ligament fibroid (10), neurofibroma (6), hemangioma (3), and benign fibrous histiocytoma (2).
Among the 20 malignant neoplasms, the lesions were colorectal carcinoma (5) [Figure 1], ovarian carcinoma (3) [Figure 2], GIST of the sigmoid colon (1), melanocarcinoma of the rectum (1), high-grade urothelial carcinoma (1), prostatic adenocarcinoma (1), seminoma of undescended testes (2), lymph node metastasis (2), non-Hodglik's lymphoma (NHL) (1), malignant fibrous histiocytoma (MFH) (1) [Figure 3], liposarcoma (1), and Primitive nurectodermal tumor (PNET) (1).
The lesions arising from ovary and broad ligament fibroid were obviously seen only in females and all the cases of prostatic adenocarcinoma and seminoma were seen in males.
The gender distribution of all other cases is shown in [Table 2]. Of the colorectal carcinoma cases, 3 cases were seen in male patients and 2 cases were seen in female patients. The GIST case and the urothelial carcinoma were seen in male patients, whereas melanocarcinoma was found in a female patient. The MFH, liposarcoma, and PNET cases were seen in male patients. We had 2 cases of metastatic lymph node as a pelvic mass in which 1 case each was seen in a male and a female. The single case of NHL was seen in a male patient. The lymph node masses in the pelvic cavity presented as lymphoedema of both legs and heaviness in the perineum. The urine of these patients was also mildly chyluric. However, the primary sites of malignancies of the metastatic lymph nodes could not be detected. We took the help of immunohistochemistry to specify the case of NHL.
The age of the patients in most neoplastic cases was above 40 years old except for the patient with testicular seminoma and the patient with twisted ovarian cysts who were seen before the age of 40. Most cases of colorectal carcinoma and all cases of ovarian carcinoma, prostatic adenocarcinoma, and urothelial carcinoma were detected after 60 years of age. Only 2 cases of colorectal carcinoma, all soft tissue neoplasms, GIST, and melanocarcinoma cases were detected in between 50 to 60 years. All cases of lymph node masses were detected between 40 to 50 years [Table 2]. Overall, it was observed that most cases of pelvic lesions are non neoplastic in nature. Among the neoplastic lesions, cases in females far outnumbered those seen in males and most of the female cases were benign neoplasms with presentation below 50 years of age. Possibly, the internal genital organ of females is subjected to more stress either hormonally or genetically and is more prone to developing neoplasms.
Most cases had a common clinical presentation of heaviness in the perineum or lower abdomen, backache, and partial obstructive features during defecation and micturition.
Hematuria was present in the patients who had bladder carcinoma, prostatic adenocarcinoma, and ovarian adenocarcinoma. Pallor was remarkably associated with the patients who had colorectal carcinoma and melanocarcinoma. Bilateral leg edema was seen in the patients who had soft tissue tumors and lymph node masses.
| Discussion|| |
It is very difficult to find the true incidence of the different types of neoplastic lesions in the pelvic cavity in different age groups and genders. The study results vary from place to place. The case series reported in totality are very few. Incidences of organ-wise neoplastic lesions are available in literature.
Moreover, the clinical diagnosis of pelvic mass can create a dilemma in many cases. A full bladder, hematocolpos, pregnancy, or mesenteric cyst should also be considered in a differential diagnosis. Different imaging techniques often fail to differentiate the lumps with certainty and laparotomy and pelvic cavity exploration only reveal the site of origin. 
Twisted ovarian cysts are very common presenting features in mature teratomas and other germ cell tumors of the ovary and patients of a younger age come to surgeons with lower abdominal pain in an emergency situation. In our series also, those with twisted ovarian cysts were below 40 years of age. On histopathology, almost all of those cases were revealed as mature teratoma except one who had a mixed germ cell component. As per world literature, germ cell tumors usually present as a twisted ovarian mass in the younger age group and constitutes 15-20% of all ovarian tumors. 
Leiomyoma or fibroids in the uterus are perhaps the most common tumor in humans. These benign tumors may be present in about 75% of females in the reproductive age group.
When these fibroids become extrauterine or disseminated in peritoneum and produce pelvic symptoms and imaging cannot determine the nature of mass, the cases are referred to surgeons. In our series, we also had 10 such cases of fibroids in females younger than 50 years old in whom a laparotomy revealed fibroids of different sizes attached to the broad ligament. Removal of these fibroids gave the patients relief from their symptoms. But questions remained whether these fibroids were detached subserous uterine fibroids or arose out of the soft tissue of the pelvic cavity.  Among the benign neoplasms in our study, neurofibroma was found in 6 cases. This kind of plexiform neurofibroma is usually seen in deep-lying soft tissues, retroperitoneum, and in the gastrointestinal (GI) tract.  A problem arises for a surgeon to dissect the tumor properly from such a closed pelvic cavity. The vascular tumors in our series were two in number, of which one was cystic lymphangioma and other was vascular hamartoma. Both were seen in children.  Out of two cases of BFH, one case had calcifications and was difficult to distinguish from calcifying fibrous pseudotumor.
The malignant lesions of the colorectal region were adenocarcinoma arising from the sigmoid colon (most common), rectum, and anal canal. Mostly, they were detected in Dukes' Stage IV involving the surrounding organs and pushing the surgeon to identify the site of the primary lesion. Moreover, in females it is difficult to distinguish these cases from ovarian adenocarcinomas involving the bowel and bladder. Even pre-operative fine needle aspiration cytology (FNAC) in such a closed cavity could not help to identify the site of origin. However, estimation of tumor markers such as CEA and CA-125 in those cases along with histopathology helped us to reach a definite diagnosis.  It was difficult to give a diagnosis of a huge mass of GIST from the sigmoid colon, which was thought to be a neural tumor of soft tissue origin.  The soft tissue sarcomas of the pelvic cavity were difficult to resect out completely among which, one was MFH, one was myxoid liposarcoma, and one was PNET histologically in our series. All three cases presented with vague lower abdominal pain and bilateral leg edema due to deep vein thrombosis. The PNET case was to be differentiated from other small round cell tumors presenting in patients of a younger age.  It was difficult to give a clear-cut diagnosis of a seminoma case in undescended testes by a pre-operative guided FNAC  because smears showed small round to oval cells with open chromatin admixed with lymphocytes, thus leading the differential diagnosis to intermediate-grade NHL. However, post-operative histology confirmed that to be a case of seminoma. We took the help of a immunohistochemical marker for specifying the type of NHL. The cases of lymphnode metastasis were possibly deposited from primaries outside of the pelvic cavity. 
The rest of the cases, such as bladder carcinoma, prostatic adenocarcinoma, and rectal melanocarcinoma were obvious in their histological appearances.
| Conclusions|| |
Overall, in our series, the incidences of different neoplastic lesions in the pelvic cavity cannot be compared with other such case-series because of the paucity of a similar report. In this sense, it is a unique study and this sort of report should be done regularly in different institutes to make a document to help surgeons adopt an early management protocol for lesions in such an unapproachable site. Pathologists also have to play a major role to give the earliest diagnosis possible with the help of modern equipment.
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Nirmal K Bhattacharyya
Flat 4A, Shanti Apartments, 7/3, Motijheel Avenue, Kolkata 74
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]