emergency surgical team were summoned urgently to the radiological suite. The combination of evacuating the barium and insufflated air had produced a ...
1985, The British Journal of Radiology, 58, 88-90
Case reports prevented sigmoidoscopy of the proximal rectum and colon. nant transformation occurs in 20-50% and is assoBiopsy showed a villous adenoma with moderate dysplasia. ciated with areas of induration, fixation, ulceration and Urea and electrolytes, chest X ray, and liver function tests were is significantly more frequent in tumours more than within normal limits. His anaemia was corrected by 4 cm in diameter (Takolander, 1977). transfusion and oral iron therapy. Because of the large size of Barium enema is mandatory to help delineate the site the tumour and the long history, malignant change seemed likely and accordingly a radical surgical approach was and size of the lesion and to exclude synchronous adenoma and carcinoma which are present in 25% of planned. A barium enema was carried out in order to delineate the cases (Thomson, 1977). Local excision is curative for precise site and size of the tumour—characteristics which non-invasive lesions, but radical resection is necessary would determine the surgical approach. This showed a massive once malignant change has taken place (Welch & villous adenoma completely filling the rectum, with a normal Welch, 1976). proximal colon (Fig. 1A). At the end of the procedure the The surgical approach for large low tumours ranges emergency surgical team were summoned urgently to the from trans-anal excision to abdomino-perineal resection radiological suite. The combination of evacuating the barium and insufflated air had produced a dramatic prolapse of the (Parks & Stuart, 1973). In our patient the massive size tumour, which lay hanging in the perineum (Fig. 1B). Attempts precluded adequate assessment of the local features, to reduce the tumour were unsuccessful, but under general making the decision regarding surgical approach anaesthesia it was found to be hanging on a pedicle with a difficult. It was therefore fortunate that the barium narrow 2 cm base originating 2 cm above the dentate line. On enema proved to be both diagnostic and therapeutic. careful examination there were no local features suggestive of malignant change. A submucous resection of the tumour with 1 cm clearance was carried out and the mucosal defect was REFERENCES closed. The excised tumour measured 12 x 10x9 cm, and on MCKITTRICK, L. S. & WHEELOCK, F. C , 1954. Carcinoma of microscopic examination showed a dysplastic villous adenoma the Colon. (Thomas, Springfield, 111.) without malignant transformation. PARKS, A. G. & STUART, A. E., 1973. The management of The patient made an uncomplicated recovery and is diseasevillous tumours of the large bowel. British Journal of free 18 months later. His haemoglobin is now 14.4 g/dl and his Surgery, 60, 688-695. weight 89 kg. QUAIN, R., 1857. Illustrations of a Peculiar Bleeding Tumour of the Rectum. (Walton & Maberly, London.) DISCUSSION TAKOLANDER, R. J., 1977. Villous papilloma of the colon and Interventional radiology has had a major impact on rectum. Ada Chirugica Scandinavica, Supplement 473. the management of gastrointestinal bleeding in recent THOMSON, J. P. S., 1977. Treatment of sessile villous and tubulovillous adenomas of the rectum; experience at St. years, but as far as we are aware this particular form of Mark's Hospital 1963-1972. Diseases of Colon & Rectum, intervention has not been previously described. 20, 467-472. The appearances and natural history of "this peculiar
bleeding tumour" were first described by Sir Richard Quain (1857). The majority present with rectal bleeding, mucous discharge and diarrhoea, although 10% are asymptomatic and 5% develop shock due to excessive potassium loss (McKittrick & Wheelock, 1954). Malig-
WELCH, J. P. & WELCH, C. E., 1976. Villous adenomas of the
colorectum. American Journal of Surgery, 131, 185-191. WHEAT, M. W. & ACKERMAN, L. V., 1958. Villous adenomas of
the large intestine: clinicopathologic evaluation of 50 cases of villous adenoma with emphasis on treatment. Annals of Surgery, 147, 476-487.
Computed tomography and ultrasound of a urachal cancer By *E. J. Fitzgerald, M.B., M.R.C.P.I., F.R.C.R. and M. Pirani, M.B., F.R.C.P.(C) Department of Diagnostic Radiology, McMaster University Medical Centre, 1200 Main Street West Hamilton, Ontario L8N 3Z5, Canada {Received April 1984)
Malignant lesions of the urachus are rare. Fewer than 200 cases have been reported in the world literature. Prior to the advent of ultrasound and computed tomography (CT), radiography was said to be of limited value in the pre-operative diagnosis of these
tumours (Beck et al, 1970). Urachal tumours have characteristic features on both ultrasound and CT scan, and these are well illustrated in our case. To our knowledge, this is the first time metastatic deposits from such a tumour have been documented on CT.
*Present address: Department of Radiology, University Hospital of Wales, Heath Park, Cardiff CF4 4XW
A 66-year-old man presented with pain in his left hip. Radiography of his pelvis (Fig. 1) revealed an oval densely
CASE REPORT
1985, The British Journal of Radiology, 58, 88-90
Case reports prevented sigmoidoscopy of the proximal rectum and colon. nant transformation occurs in 20-50% and is assoBiopsy showed a villous adenoma with moderate dysplasia. ciated with areas of induration, fixation, ulceration and Urea and electrolytes, chest X ray, and liver function tests were is significantly more frequent in tumours more than within normal limits. His anaemia was corrected by 4 cm in diameter (Takolander, 1977). transfusion and oral iron therapy. Because of the large size of Barium enema is mandatory to help delineate the site the tumour and the long history, malignant change seemed likely and accordingly a radical surgical approach was and size of the lesion and to exclude synchronous adenoma and carcinoma which are present in 25% of planned. A barium enema was carried out in order to delineate the cases (Thomson, 1977). Local excision is curative for precise site and size of the tumour—characteristics which non-invasive lesions, but radical resection is necessary would determine the surgical approach. This showed a massive once malignant change has taken place (Welch & villous adenoma completely filling the rectum, with a normal Welch, 1976). proximal colon (Fig. 1A). At the end of the procedure the The surgical approach for large low tumours ranges emergency surgical team were summoned urgently to the from trans-anal excision to abdomino-perineal resection radiological suite. The combination of evacuating the barium and insufflated air had produced a dramatic prolapse of the (Parks & Stuart, 1973). In our patient the massive size tumour, which lay hanging in the perineum (Fig. 1B). Attempts precluded adequate assessment of the local features, to reduce the tumour were unsuccessful, but under general making the decision regarding surgical approach anaesthesia it was found to be hanging on a pedicle with a difficult. It was therefore fortunate that the barium narrow 2 cm base originating 2 cm above the dentate line. On enema proved to be both diagnostic and therapeutic. careful examination there were no local features suggestive of malignant change. A submucous resection of the tumour with 1 cm clearance was carried out and the mucosal defect was REFERENCES closed. The excised tumour measured 12 x 10x9 cm, and on MCKITTRICK, L. S. & WHEELOCK, F. C , 1954. Carcinoma of microscopic examination showed a dysplastic villous adenoma the Colon. (Thomas, Springfield, 111.) without malignant transformation. PARKS, A. G. & STUART, A. E., 1973. The management of The patient made an uncomplicated recovery and is diseasevillous tumours of the large bowel. British Journal of free 18 months later. His haemoglobin is now 14.4 g/dl and his Surgery, 60, 688-695. weight 89 kg. QUAIN, R., 1857. Illustrations of a Peculiar Bleeding Tumour of the Rectum. (Walton & Maberly, London.) DISCUSSION TAKOLANDER, R. J., 1977. Villous papilloma of the colon and Interventional radiology has had a major impact on rectum. Ada Chirugica Scandinavica, Supplement 473. the management of gastrointestinal bleeding in recent THOMSON, J. P. S., 1977. Treatment of sessile villous and tubulovillous adenomas of the rectum; experience at St. years, but as far as we are aware this particular form of Mark's Hospital 1963-1972. Diseases of Colon & Rectum, intervention has not been previously described. 20, 467-472. The appearances and natural history of "this peculiar
bleeding tumour" were first described by Sir Richard Quain (1857). The majority present with rectal bleeding, mucous discharge and diarrhoea, although 10% are asymptomatic and 5% develop shock due to excessive potassium loss (McKittrick & Wheelock, 1954). Malig-
WELCH, J. P. & WELCH, C. E., 1976. Villous adenomas of the
colorectum. American Journal of Surgery, 131, 185-191. WHEAT, M. W. & ACKERMAN, L. V., 1958. Villous adenomas of
the large intestine: clinicopathologic evaluation of 50 cases of villous adenoma with emphasis on treatment. Annals of Surgery, 147, 476-487.
Computed tomography and ultrasound of a urachal cancer By *E. J. Fitzgerald, M.B., M.R.C.P.I., F.R.C.R. and M. Pirani, M.B., F.R.C.P.(C) Department of Diagnostic Radiology, McMaster University Medical Centre, 1200 Main Street West Hamilton, Ontario L8N 3Z5, Canada {Received April 1984)
Malignant lesions of the urachus are rare. Fewer than 200 cases have been reported in the world literature. Prior to the advent of ultrasound and computed tomography (CT), radiography was said to be of limited value in the pre-operative diagnosis of these
tumours (Beck et al, 1970). Urachal tumours have characteristic features on both ultrasound and CT scan, and these are well illustrated in our case. To our knowledge, this is the first time metastatic deposits from such a tumour have been documented on CT.
*Present address: Department of Radiology, University Hospital of Wales, Heath Park, Cardiff CF4 4XW
A 66-year-old man presented with pain in his left hip. Radiography of his pelvis (Fig. 1) revealed an oval densely
CASE REPORT
JANUARY 1985
Case reports
FIG.
3.
Post-contrast CT scan of pelvis showing the calcified mass. No enhancement of the tumour occurred after intravenous contrast. (W 250, L 50).
FIG.
normal on CT at this stage. Because of the position of this lesion, a diagnosis of a urachal tumour was made. Unfortunately, the patient refused surgical treatment. He returned 18 months later complaining of some weight loss and lassitude. Clinically the mass had increased in size and a repeat ultrasound scan confirmed the increase in size and additionally showed several hypoechoic lesions of the liver, suggestive of metastases. A repeat CT scan showed new calcified foci behind the densely calcified pelvic mass; small calcified lesions were also present in the hepatorenal fossa (Fig. 4) and the paracolic gutter. A mass of fluid density resulting from ascites was seen outlining the surface of the liver. On the basis of these findings, widespread intraperitoneal spread was reported. Laparotomy was planned, but prior to surgery the patient suffered a cardiac arrest. At autopsy, a mucinous, multilocular, calcified, supravesical tumour was found. Mucinous, calcified
1.
Calcified pelvic mass seen on presentation (arrows). calcified pelvic mass 8-10 cm in diameter. Urography was normal. Ultrasound scanning (Fig. 2) showed a complex mass lying anteriorly, above the bladder and extending cephalad. CT scan (Fig. 3), carried out soon after the ultrasound scan, confirmed these findings, demonstrating a midline 6 x 6 x 1 0 cm mass with dense peripheral calcification. This mass was located in the vicinity of the bladder apex and extended towards the umbilicus. No enhancement occurred after intravenous contrast. The remainder of the abdomen was
FIG. FIG.
2.
4.
Abdominal CT scan showing a partially calcified mucinous deposit lying between the liver and right kidney (arrow). Measurement cursors are seen over the liver and ascites. (W 250, L50).
Longitudinal ultrasound scan, (head on left, bladder on right) showing a complex supravesical mass extending towards the umbilicus.
89
VOL.
58, No. 685 Case reports
deposits of varying size were present throughout the peritoneal spaces, as revealed by CT. Additionally, several mucinous liver deposits were present. All other organs were normal. Histologically, the tumour was a mucin-secreting adenocarcinoma. The tumour fulfilled Mostofi's criteria (Mostofi et al, 1955) for diagnosis of a primary urachal adenocarcinoma. DISCUSSION
The urachus is a vestigial remnant of the allantois, which in the fetus communicates with the cloaca. In the adult, it is a musculofibrous tube occupied by desquamated epithelium. It lies in the space of Retzius, bounded by the transversalis fascia and the peritoneum, extending towards the umbilicus. In 33% of people it opens directly into the bladder (and thus may be visible on urography or cystography); in the majority it ends as a blind pouch in the bladder wall (Begg, 1931). Urachal cancer is said to represent 0.01% of all primary malignancies (Cornil et al, 1967). Three times as many men as women suffer from it. It mainly affects the middle-aged and elderly, but a case has been reported in a 15-year-old (Cornil et al, 1967). The great majority of cases are mucin-producing adenocarcinomas (94%), the remainder being transitional or squamous-cell; very rarely anaplastic types occur (Beck et al, 1970). Clinically, haematuria is the commonest presenting symptom (Whitehead & Tessler, 1971). Other symptoms are dysuria, frequency or abdominal pain. Passage of mucoid material is said to be pathognomic, but occurs in only 10% of cases (Grogono & Shepheard, 1969). Cystoscopy is necessary for histological diagnosis. However, cystoscopic biopsy may not distinguish between benign and malignant urachal remnants (Bourne & May, 1977). Therefore, several authors suggest that all urachal remnants to which symptoms may be attributed should be surgically removed both for diagnosis and prevention of complications (Bourne & May, 1977). Prior to the advent of cross-sectional imaging methods radiology played little part in the pre-operative diagnosis of such tumours. Rarely, calcification may be seen on the abdominal radiograph (Pollock, 1952; Taylor & McRae, 1978). On urography, deformity of the bladder apex can be seen, but again this is infrequent, occurring in 11.5% of 78 cases (Beck et al, 1970). Both CT and ultrasound can accurately localise the tumour to the space of Retzius. The extra-peritoneal location of the urachus makes it directly accessible to
90
ultrasound without interference from overlying loops of bowel. Ultrasound is also useful in showing the size of such lesions; CT similarly helps successful pre-operative diagnosis of urachal tumours. It shows accurately the relationship between the mass and the bladder, and the degree of extension of the mass towards the umbilicus. CT may also show any calcification not visible on plain films, thus enhancing the specificity of the diagnosis (Kwok-Liu et al, 1980). Both modalities can be used to direct fine-needle aspiration of such lesions to obtain histological material (Spataro et al, 1983). As in our case, CT may help in staging the tumour by demonstrating secondary deposits. It may also be used in follow-up of surgically treated patients. CONCLUSION
If, on CT or ultrasound, a mass lesion, whether calcified or not, is shown in the space of Retzius extending towards the umbilicus, the possibility of a urachal tumour should be strongly considered. REFERENCES BECK, A.
D.,
GAUDIN, H.
J. & BONHAM, D.
G.,
1970.
Carcinoma of the urachus. British Journal of Urology, 42, 555-562. BEGG, R. C , 1931. Colloid adenocarcinoma of the bladder vault arising from the epithelium of the urachal canal; with critical survey of tumours of the urachus. British Journal of Surgery, 18, 422-466. BOURNE, C. W. & MAY, J. E., 1977. Urachal remnants: benign or malignant? Journal of Urology, 118, 1^1-lM. CORNIL, C , REYNOLDS, C. T. & KICKHAM, C. J. E., 1967.
Carcinoma of the urachus. Journal of Urology, 98, 93-95. GROGONO, J. L. & SHEPHEARD, B. G. F., 1969. Carcinoma of
the urachus. British Journal of Urology, 41, 222-227. KWOK-LIU, J. P., ZlKMAN, J. M . & COCKSHOTT, W. P., 1980.
Carcinoma of the urachus: The role tomography. Radiology, 137, 731-734.
of computed
MOSTOFI, F. K., THOMSON, R. V. & DEAN, A. L., JR., 1955.
Mucous adenocarcinoma of the urinary bladder. Cancer, 8, 741-758. POLLOCK, A. V., 1952. A case of adenocarcinoma of the urachus showing extensive calcification. British Journal of Surgery, 40, 187-188. SPATARO, R. F., DAVIS, R. S., MCLACHLAN, M. S. F., LINKE,
C. A. & BARBARIC, Z. L., 1983. Urachal abnormalities in the adult. Radiology, 149, 659-663. TAYLOR, G. D. & MCRAE, C. U., 1978. Carcinoma of the
urachus: Report of four cases and review of the literature. New Zealand Medical Journal, 87, 384-386. WHITEHEAD, E. D. & TESSLER, A. N., 1971. Carcinoma of the
urachus. British Journal of Urology, 43, 468-476.
