Ankara Üniversitesi Tıp Fakültesi Mecmuası 2017, 70 (3) CERRAHİ TIP BİLİMLERİ/ SURGICAL SCIENCES DOI: 10.1501/Tıpfak_000000987 Araștırma Makalesi / Research Article

Diagnosis and Treatment Approaches for Intraabdominal Masses in Adults

Erișkin İntraabdominal Kitlelerinde Tanı ve Tedavi Yaklașımları

Muzaffer Akkoca1, Serhat Tokgöz1, Kerim Bora Yılmaz1, Melih Akıncı1, Demet Yılmazer2

1 Department of General , University of Health Sciences, Dışkapı Yıldırım Beyazıt Research and Training Hospital, Aim: To evaluate patients who underwent surgery because of an intra-abdominal mass, in respect of Ankara/Turkey 2 Department of Pathology, University of Health Sciences, Dışkapı symptoms, findings, diagnosis and treatment in accordance with information in literature. Yıldırım Beyazıt Resea rch and Training Hospital, Ankara/Turkey Material and Methods: A retrospective examination was made of patients who underwent surgery because of an intra-abdominal mass between May 2010 and May 2017. For each patient a record was made of age, gender, symptoms, findings, type of mass determined, diagnostic methods used, the organ or tissue of origin, whether or not preoperative biopsy was taken, dimension of the mass, benign or malignant nature of the mass, type of operation performed and pathological diagnosis. Results: Evaluation was made of 45 patients with an intra-abdominal mass. The patients comprised 18 (40%) males and 27 (60%) females with a mean age of 54.3 years (range, 19-86 years). The most common symptom was abdominal in 26 (57.8%) patients, and being able to feel the mass in the in 15 (33.4%). The intra-abdominal mass could be determined on palpation in 28 (62.2%) as a finding in the . USG was the most preferred imaging examination method in 36 (80%) patients, followed by CT in 28 (62.2%), MRI in 10 (22.2%) and PET-CT in 2 (4.4%). Preoperative endoscopy was applied to 27 (60%) patients and biopsy to 21 (46.7%). The long axis of the mass was mean 13cm (range, 4-50 cm). Treatment was applied as total excision of the mass in 29 (64.4%) patients, enbloc resection of the mass together with the bowel in 14 (31.1%), together with a distal pancreatectomy in 1 (2.2%) and together with a pancreaticoduodenectomy in 1 (2.2%). The pathology result was reported as benign in 15 (33.3%) patients and as malignant in 30 (66.7%). Of the benign masses, mesenteric cyst was determined most frequently in 5 (11.1%) patients and gastrointestinal stromal tumors (GIST) were determined as the most common malignant masses in 10 (22.2%) patients. Conclusion: Although intra-abdominal masses originate from different organs and have different clinical and histopathological properties, they are pathologies that require systematic evaluation in respect of diagnosis and treatment approaches. Key Words: Intra-Abdominal Masses, Physical Examination, Abdominal Ultrasonography, Histopathological Type, Gastrointestinal Stromal Tumor. Amaç: Bu çalıșma ile; karın içi kitle nedeni ile ameliyat edilen hastaların; semptom, bulgu, tanı ve tedavi sistematiği açısından literatür bilgileri doğrultusunda değerlendirilmesi amaçlandı. Gereç ve Yöntem: Mayıs 2010- Mayıs 2017 tarihleri arasında karın içi kitle nedeni ile ameliyat edilen hastalar geriye dönük olarak incelendi. Karın içi kitle nedeni ile ameliyat edilen hastaların; yaș, cins, semptom, semptom, bulgu, kitlenin tespit edilme șekli, hangi tanı yöntemi ile tespit edildiği, hangi organ veya dokudan köken aldığı, ameliyat öncesi biyopsi yapılıp yapılmadığı, kitlenin boyutu, kitlenin benign veya malign olușu,hangi ameliyatın yapıldığı ve patolojik tanının ne olduğu belirlendi. Bulgular: Çalıșmaya dahil edilen karın içi kitleli 45 hastanın ortalama yașının 54,3 (19-86) olduğu 18’inin erkek (%40), 27’sinin ise kadın (%60) olduğu görüldü. En fazla semptom 26 hastada (%57,8) karın ağrısı, 15 hastada ise (%33,4) abdomende ele gelen kitle idi. Fizik muayene bulgusu olarak 28 hastada (%62,2) palpasyonda karın içi kitle tespit edilebildi. Görüntüleme çalıșmalarından en fazla tercih edilen 36 hasta (%80) ile abdomen ultrasonografi (USG) idi. USG’yi 28 (%62,2) hasta ile abdomen bilgisayarlı tomografi (BT), 10 hasta ile (%22,2) abdomen manyetik rezonans görüntüleme (MRG), 2 hasta ile (%4,4) pozitron emisyon tomografi-bilgisayarlı tomografi (PET-BT) takip etmekte idi. Ameliyat öncesi 27 hastaya (%60) endoskopi, 21 hastaya da (%46,7) biyopsi yapıldığı görüldü. Kitlelerin uzun ekseni ortalama 13cm (4cm-50cm) idi. 29 hastanın (%64,4) kitlenin total olarak eksize edilmesi ile, 14 hastanın (%31,1) kitlenin barsak rezeksiyonu ile birlikte enblok rezeke edilmesi ile, 1 hastanın (%2,2) distal pankreatektomi ile, 1 hastanın da (%2,2) pankreatikoduodenektomi ile Received: Nov. 17, 2017  Accepted: Dec. 19, 2017 birlikte tedavi edildiği saptandı. 15 hastanın (%33,3) patoloji sonucu benign, 30 hastanın (%66,7) ise malign Corresponding Author: olarak raporlandığı görüldü. Benign kitlelerden en sık mezenter kistine (n:5, %11,1), malign kitlelerden ise gastrointestinal stromal tümörlere (GİST) (n:10, %22,2) rastlandı. Muzaffer Akkoca Tartıșma ve Sonuç: Karın içi kitleler; farklı organlardan köken alan, farklı klinik ve histopatolojik özelliklere E-mail: [email protected] sahip olan kitleler olmakla birlikte tanı ve tedavi yaklașımları açısından sistematik değerlendirilmesi gereken Mobil phone: 0 505 649 74 43 Fax/phone: 90 (312) 596 23 12 patolojilerdir. Department of General Surgery, University of Health Sciences, Dıșkapı Yıldırım Beyazıt Research and Training Hospital, Anahtar Sözcükler: İntraabdominal Kitle, Fizik Muayene, Abdominal Ultrasonografi, Histopatholojik Tip, Altındağ/Ankara 06110, Turkey Gastrointestinal Stromal Tümör.

Ankara Üniversitesi Tıp Fakültesi Mecmuası 2017, 70 (3)

Intra-abdominal masses are defined as knowledge, there has been no Results masses located at the edges of the ribs previous study that has examined and in the region of the paraspinal intra-abdominal masses in general in The study included a total of 45 patients muscles limited in the anterior by the respect of the symptoms, findings, with an intra-abdominal mass, iliac wings and the symphysis pubis diagnostic approaches and treatment comprising 18 (40%) males and 27 (1). Generally, intra-abdominal masses methods. (60%) females with a mean age of 54.3 are determined as a result of years (range, 19-86 years). The most symptoms in the abdomen or in a The aim of this study was to systematically common symptom was abdominal physical examination or incidentally evaluate cases operated on in our pain in 26 (57.8%) patients. A total of during radiological imaging clinic because of intra-abdominal 15 (33.4%) patients presented with the performed for another reason. mass in respect of symptoms, complaint of being able to feel the Evaluation of intra-abdominal masses findings, diagnosis and treatment in mass in the abdomen (Table 1). In is based on knowledge of the anatomy the light of the relevant information in some patients, there was more than of the abdomen and which quadrant literature. one symptom, 1 (2.2%) patient corresponds to the organs of the underwent emergency surgery abdomen. In a basic anatomic Material and Method because of intra-abdominal bleeding approach, the abdomen is separated and in 3 (6.6%) patients, there were no into 9 areas of epigastric, umbilical, Approval for the study was granted by the symptoms. The intra-abdominal mass suprapubic, right hypochondrium, left Local Ethics Committee. A could be determined on palpation in hypochondrium, right lumbar, left retrospective examination was made 28 (62.2%) as a finding in the physical lumbar, right inguinal and left inguinal of patients operated on because of an examination, and the mass could not regions. However, in clinical practice, intra-abdominal mass in the General be palpated in 17 (37.8%). USG was the terms more often used, especially Surgery Clinic of Ankara Dışkapı the most preferred imaging by surgeons, are the right upper and Yıldırım Beyazıt Training and examination method in 36 (80%) right lower quadrant, left upper and Research Hospital between May 2010 patients, followed by abdominal CT in left lower quadrant, epigastric and and May 2017. The data related to the 28 (62.2%), abdominal MRI in 10 hypogastric regions (2). patients were retrieved from hospital (22.2%) and PET-CT in 2 (4.4%) records, operating reports, operation (Figure 1). More than one imaging As these masses are seen in a widely photographs, the epicrisis reports method was used in some patients. varying range, it is not correct to recorded in the hospital automated group them under a single diagnostic Table 1. Data on demographic and diagnostic information system, laboratory, evaluations of the patients. category or to apply the same imaging and pathological examination Number of Percentage diagnostic and treatment methods. reports. For each patient a record was patients (n) (%) Knowing that there can be several made of age, gender, symptoms, 45 100 Gender pathologies under the heading of findings, the type of mass determined, Male 18 40 intra-abdominal mass and what type diagnostic methods used, the organ or Female 27 60 of masses there could be in which tissue of origin, whether or not Symptom 26 57,8 regions of the abdomen with which preoperative biopsy was taken, Mass 15 33,4 symptoms and findings, and the need dimension of the mass, benign or Hemorrhagea 1 2,2 for systematic follow-up of which None 3 6,6 malignant nature of the mass, type of Physical methods are used in the approach to operation performed and pathological examination 28 62,2 these, demonstrates the need for Palpable 17 37,8 diagnosis. Data and analyses related to Not palpable evaluation of these pathologies under imaging examinations made during Imaging methods a heading. diagnosis were taken from the USG 36 80 BT 28 62,2 Radiology Clinic and data and analyses There are reports in literature of MRI 10 22,2 related to the histopathological PET-BT 2 4,4 diagnostic, treatment and follow-up diagnosis from the Pathology Clinic. Endoscopy approaches for intra-abdominal No 18 40 Cases were excluded from the study if masses caused by various diseases. Yes 27 60 there were no clear findings of a mass - Upper GIS 9 20 Although these pathologies are more - Lower GIS 18 40 in the physical examination or on often presented in the form of single Preoperative biopsy imaging examination, if there was an No 24 53,3 case reports, there are also case series endoluminal mass of the Yes 21 46,7 and research papers on a specific -USG guided 17 37,8 gastrointestinal system or if data were -CT guided 4 8,8 diagnosis. However, to the best of our incomplete or unavailable.

202 Diagnosis and Treatment Approaches for Intraabdominal Masses in Adults Journal of Ankara University Faculty of Medicine 2017, 70 (3)

Figure 1. a) The CT image of the jejunum-derived GIST, b) MRI image of Schwannom in the retrorectal region c) CT image of over tumor filling the abdomen a) GIST b) Retrorectal schwannoma c) Over tumor

Figure 2: a) Post-operative specimen of Gastrointestinal stromal tumor (GIST), b) Post-operative specimen of Schwannom in the retrorectal region, c) Post-operative specimen of over tumor. a) GIST b) Retrorectal schwannoma c) Over tumor

According to the data obtained from the (Figure 2). The mean length of When the pathology results of the patients operating notes, the long axis of the hospital stay was 7.2 days (ra nge, 3-16 were examined, the mass was reported mass was measured as mean 13cm days) and the mortality rate was as benign in 15 (33.3%) patients and as (range, 4-50 cm). The smallest mass determined as 4.4% (n:2) (Table 2). malignant in 30 (66.7%). The most with the long axis of 4 cm was seen to frequently determined histopathological Table 2. Tumor localization and type of be related to endometriosis and the surgery diagnosis of the benign masses was largest with the long axis of 50 cm was Number of Percentage mesenteric cyst (n:5, 11.1%) and of the determined as an intra-abdominal patients (n) (%) malignant masses, gastrointestinal mass related to liposarcoma. The Tumor localization stromal tumors (GIST) (n:10, 22.2%) Mesenter 18 40 origin of the intra-abdominal mass Retroperiton 10 22,2 (Table 3). was seen to be the intestinal mesentery Over 5 11 Anterior wall of Table 3. Histopathologic types and rates of in most cases (n:18), followed by the abdomen 4 8,8 intraabdominal masses. retroperitoneum (n:10), the ovary Pancreas 2 4,4 Omentum 2 4,4 Benign n Malign n (%) (n:5), and the abdominal anterior wall Stomach 1 2,2 Pathologies (%) Pathologies Duodenum 1 2,2 Mesenter cyst 5 11,1 GIST 10 22,2 (n:4). As treatment, total excision of Small intestine 1 2,2 Endometriosys 2 4,4 Liposarcoma 7 15,6 the mass was applied to 29 (64.4%) Colon 1 2,2 Cyst hydatic 2 4,4 Over tumor 5 11,1 patients, enbloc resection of the mass Type of surgey Fibroma 2 4,4 Condrosarcom 2 4,4 Total excision 29 64,4 Distrofic 1 2,2 Neuroendocrin 2 4,4 together with the bowel to 14 (31.1%), Enbloc resection of the mass calcification tumor together with a distal pancreatectomy together with the bowel 14 31,1 Aberran 1 2,2 Malign 2 4,4 Distal pancreatectomy 1 2,2 pancreas mesenchimal tumor in 1 (2.2%) and together with a Pancreaticoduodenectomy 1 2,2 Leiomyoma 1 2,2 Lymphoma 1 2,2 pancreaticoduodenectomy in 1 (2.2%) Pseudocyst 1 2,2 Schwannoma 1 2,2 Total 15 33,3 Total 30 66,7

Muzaffer Akkoca, Serhat Tokgöz, Kerim Bora Yılmaz, Melih Akıncı, Demet Yılmazer 203 Ankara Üniversitesi Tıp Fakültesi Mecmuası 2017, 70 (3)

Discussion examination an abdominal mass could However, despite the above-mentioned only be palpated in 28 patients. This advantages of USG, because it is Abdominal masses include several result indicates the importance of the dependent on the practitioner’s different pathological lesions with physical examination. In the experience and in some cases where it benign or malignant properties, solid determination of a mass in the was insufficient for the images of or cystic and which can be different abdomen in the physical examination, intra-abdominal masses, abdominal according to age, gender, localization first it must be attempted to computed tomography (CT) was and organ or tissue of origin. For a differentiate pathological states from applied to 28 (62.2%) patients either diagnosis of a pathology with so many causes such as postural differences as the first imaging procedure or after different properties, systematic which could be normal or swelling abdominal USG (Figure 1). evaluation is necessary for the caused by obesity, gas distension, Abdominal CT is one of the most application of correct treatment. pregnancy or fecaloma. Furthermore, effective methods in current Knowledge of the different it is necessary to determine in the diagnostic and interventional pathologies causing abdominal masses physical examination whether the evaluations of intra-abdominal masses and the diagnostic and treatment mass determined requires emergency (5). Unlike USG, abdominal CT approaches to these is of particular treatment, the localization, the size, clearly shows the tissue planes without importance. the shape, the texture, the contours, any effect from gas, fat or bone whether or not it is pulsatile and structures in the abdomen and can The process of diagnosis of an intra- whether or not it is adhering to provide the surgeon with information abdominal mass starts with a detailed surrounding tissues. In 1 of the cases on the removability of the mass by history and physical examination. in the current study, as a result of the showing the borders between the These two steps form the basis of the findings of the physical examination mass and adjacent structures (6). In preliminary diagnosis and differential of the mass determined in the patients with renal failure or a contra- diagnosis by which the causes of the abdomen, there were seen to be indication to contrast material intra-abdominal mass will be findings of intra-abdominal bleeding containing iodine and in cases of determined. The patient must be and because of hemodynamic masses with pancreas or questioned in detail about symptoms, instability, the patient was admitted retroperitoneal localization, magnetic time since onset, additional for emergency surgery. This mass was resonance imaging is preferred (7). gastrointestinal symptoms, known determined to be of small intestine diseases, family history, previous mesenteric origin, and tumor To evaluate whether the intra-abdominal operations and trauma history (3). In perforation had caused intra- mass originates from hollow organs or the current study, the most frequent abdominal bleeding. The pathology of obstruction which can occur because symptom on presentation was the mass was reported to be GIST. of the effect of the mass on the abdominal pain followed by the stomach and intestines, complaint of feeling the mass in the In the physical examination, when gastrointestinal (GIS) system abdomen. Although all of the patients diagnosis cannot be made and endoscopy may be necessary. To in this study had an abdominal mass, localization or the origin of the mass evaluate endoluminal pathologies, only 13 presented with the complaint cannot be determined or benign- lower GIS endoscopy was applied to of the mass, showing that most of the malignant differentiation cannot be 40% of the current cases and upper patients were not aware of the made, imaging examinations and GIS endoscopy to 20%. Following abdominal mass. This suggests that biopsy procedures made according to imaging studies revealing the intra- masses that have not reached large these are extremely important in the abdominal mass, there may be a need dimensions can remain asymptomatic diagnosis of intra-abdominal masses. for biopsy to determine the treatment or in selected cases, it can manifest Of the imaging examinations, it is approach. While biopsy under USG with the complaint of abdominal pain. recommended that abdominal guidance is preferred in large, In this result, the size of the mass is ultrasonography (USG) is applied first superficial and cystic lesions, biopsy undoubtedly important in addition to as it is easily accessible, has no under CT guidance is preferred in the localization. It may be difficult for radiation exposure, can be applied masses with a deep location which patients to notice masses, especially rapidly and in a practical manner and cannot be visualized on USG as it has those with a deep retroperitoneal can identify the organ of origin with high rates of accuracy (8, 9). In our location or a pelvic location. solid cystic differentiation (4). In the study, preoperative USG and CT diagnostic evaluation in the current guided biopsy rates is similar to the According to the study results, although study, abdominal USG was applied to literure. the majority of the patients had 80% of the patients. complaints of a mass, in the physical

204 Diagnosis and Treatment Approaches for Intraabdominal Masses in Adults Journal of Ankara University Faculty of Medicine 2017, 70 (3)

In the majority of cases, the abdominal mass As intra-abdominal masses more often several different histopathological could be totally removed with intact have exophytic growth, they can types of mass originating from several surgical borders. However, in some manifest clinically and the surgical different organs were seen (Table 3). patients, resection of the colon or small strategy is removal of the mass which intestine was necessary to be able to will obtain a negative surgical border In conclusion, as intra-abdominal masses remove the whole mass (Figure 2). The macroscopically and microscopically originate from different organs and have tumour localisation was determined as (13, 14). Liposarcoma are tumours different clinical and histopathological most frequently in the intestine which demonstrate malignant properties, they are pathologies that mesentery followed by retroperitoneal behaviour with mesenchymal origin require systematic evaluation in respect location and ovarian. Of the malignant from fat tissue. In the treatment of of diagnosis and treatment approaches. masses, the most common was these masses, which can reach a large Although, to the best of our knowledge, determined as GIST followed by size without showing symptoms, it is this is the first study in literature on this liposarcoma and the most common of again aimed to completely remove the subject, it is a fact that with an increase the benign masses was seen to be mass with a negative surgical border in the number of cases, many lesions will mesenteric cysts. GIST, which can (15-18). Mesenteric cysts are rarely be able to be seen with different clinical originate from any part of the seen, can cause symptoms of a mass and pathological properties. Therefore, , but primarily the with abdominal pain and can be there is a need for further multi-center stomach, are rarely seen masses with the removed laparoscopically or with studies to be able to establish diagnosis potential to be malignant (10,12). open surgery depending on the and treatment algorithms for intra- symptoms and localisation (19-22). In abdominal masses. the current study, apart from these,

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Muzaffer Akkoca, Serhat Tokgöz, Kerim Bora Yılmaz, Melih Akıncı, Demet Yılmazer 205