1979, British Journal of Radiology, 52, 992-993 Case reports
a positive diagnosis. In retrospect, the ultrasound features are characteristic.
COMMENT
To make the diagnosis of a calculus in the common bile duct at an ultrasound examination it is necessary to show the calculus within the duct, which is often possible (Fig. 4). The Mirizzi syndrome is uncommon and the author was not fully aware of its features. With this knowledge, and applying strict ultrasound criteria, it should be possible to make
REFERENCES CLEMETT, A. R., and LOWMAN, R. M., 1965. The Roentgen
features of the Mirizzi syndrome. American Journal of Radiology, 94, 480-483. DEWBURY, K. C , JOSEPH, A. E. A., HAYES, S., and MURRAY,
C , 1979. Ultrasound in the evaluation and diagnosis of jaundice. British Journal of Radiology, 52, 276-280.
Lipomatous tumour of the uterus: radiographic and ultrasonic appearance By L Murray Houser, M.D., C. H. Carrasco, M.D. and C. R. Sheehan, Jr., R.D.M.S. Department of Radiology, Pennsylvania Hospital, 8th and Spruce Streets, Philadelphia, Pennsylvania 19107 (Received March 1979)
Masses in the pelvis that are shown to contain fat on X-ray are usually thought to be ovarian in origin. An unusual lipomatous tumour of the uterus, seen on plain radiographs and on ultrasound, is presented. This is the first report of the pre-operative demonstration of such a tumour by X-ray or ultrasound.
and smooth muscle tissue. Most patients are postmenopausal, predominantly in their 50's and 60's although one was 23 years old. The size of the tumours vary from several millimetres to 32 cm in diameter. They may occur anywhere within the uterus, but are however, predominantly found in the corpus. Most are associated with ordinary fibroids. Grossly, they are rounded or oval and well encapsulated. The pure lipomas are soft and yellow, while the more fibrous tumours tend to be lighter in colour and firmer. Clinically, the symptoms are indistinguishable from those of ordinary fibroids. Histologically, the pure lipomas consist of mature fat cells in a spare connective tissue stroma. The
CASE REPORT
A 59-year-old white female was admitted for evaluation of a pelvic mass. She had been in good health until four days prior to admission when she noted pain in her right hip and a sensation of pressure in her pelvis. Physical examination revealed a large, hard, irregular pelvic mass extending upward to the level of the umbilicus. On the plain film of the abdomen there was a rounded mass in the pelvis measuring approximately 18 cm in diameter. The central portion of this was radiolucent and surrounded by a relatively uniform soft tissue density measuring 1—2 cm in thickness (Fig. 1). Abdominal ultrasound demonstrated a 16 cm mass with a strongly echogenic central portion, which was surrounded by a relatively echo-free' border (Fig. 2). The central portion of the mass was so attenuating that the back wall could not be seen. The radiographic and ultrasonic findings were interpreted as a soft-tissue pelvic mass with a fatty central core and assumed to represent a dermoid tumour of the ovary. At operation, the mass was found to be within the uterus and was thought to be a fibroid tumour. Total hysterectomy was performed. Gross examination of the uterus showed a large, spherical, firm mass, which on cut section was seen to be within the myometrium. It was well circumscribed and yellowish in colour. Microscopically, the tumour was composed predominantly of mature fat cells with some interposed fibrous elements and smooth muscle. The pathologic diagnosis was fibromyolipoma of the uterus. DISCUSSION
Lipomatous tumours of the uterus are relatively uncommon. Salm (1973) found seven cases 5200 speciments over a 25 year period, an incidence of 0.14%. Brandfass and Everts-Suarez (1955) summarized the world literature in a comprehensive review. They found 33 pure lipomas and 63 mixed tumours (fibromyolipomas, myolipomas and fibrolipomas) with varying amounts of fibrous
FIG.1.
Radiolucent central mass corresponds to fatty tumour. A thin rim of more radiodense material, representing the myometrium, surrounds it.
992
1979, British Journal of Radiology, 52, 993-995
DECEMBER 1979
Case reports
theories are that they arise from: (1) misplaced embryonic fat cells in the uterus, or (2) fatty metaplasia of muscle or connective tissue cells. The recognition of fatty tumours by virtue of their relative radiolucence on standard radiographs is well known. Behan and Kazam (1978) have described the ultrasonic characteristics of fatty tissues and tumours in multiple locations throughout the body. They found that in the majority of instances fat is strongly echogenic and may cast an acoustic shadow preventing the demonstration of the entire mass, as in this case. Only rarely do fatty tumours appear echo-free. While in most instances a tumour of the pelvis which is seen to be composed of fatty tissue by either X-ray or ultrasound will be of ovarian origin, a lipomatous tumour of the uterus FIG. 2. should be considered. This is the first reported case Transverse supine B-scan 6 cm above the symphysis. The of a fatty tumour of the uterus being demonstrated strongly echogenic mass (black arrows) corresponds to the fatty tumour. Note how sound is absorbed, producing a on X-ray and ultrasound.
shadow and obscuring the back wall. The narrow, relatively sonolucent rim (white arrows) corresponds to the myometrium around the tumour.
REFERENCES BEHAN, M. and KAZAM, E., 1978. The echographic charac-
teristics of fatty tissues and tumors. Radiology, 129, 143-151. BRANDFASS, R. T. and EVERTS-SUAREZ, E. A., 1955. Lipo-
mixed type of fatty tumour has varying degrees of fibrous stroma and muscle tissue. The histogenesis of these tumours is uncertain. The two most popular
matous tumors of the uterus. American Journal of Obstetrics and Gynecology, 70, 359-367. SALM, R., 1973. The histogenesis of uterine lipomas. Beitrdge zur Pathologie der Verdauungsorgane, 149, 284—292.
Neuroblastoma in a child with the hydantoin and fetal alcohol syndrome. The radiographic features By J. Ramilo, M.D., and Vivian J. Harris, M.D. Department of Pediatric Radiology, Cook County Children's Hospital, Chicago, USA (Received April 1979 and in revised form June 1979)
Fetal alcohol and fetal dilantin (hydantoin) syndromes have been recognized only recently. Both have distinguishing features mainly characterized by peculiar facies, cardiovascular disorders, psychomotor retardation, limbs and skeletal anomalies (Jones et al, 1973; Hanson et al, 1976; Meadows, 1968; Hill et al, 1974; Goodman et al, 1976; Dabee et al, 1975). The association of malignant tumours in children with fetal alcohol or fetal dilantin syndrome has been documented, although rarely (Hornstein et al, 1977; Blattner et al, 1977). Only two previous cases of neuroblastoma associated with fetal hydantoJn syndrome have been reported (Pendergrass and Hanson, 1976; Sherman and Poizen, 1976). We are reporting a third case born to a mother who was alcoholic and taking diphenylhydantoin for a seizure disorder.
CASE REPORT
A 35-month-old child was admitted to Cook County Children's Hospital for investigation of his cardiac murmur and failure to thrive. His mother was an alcoholic and had been taking diphenylhydantoin sodium (Dilantin) for seizure disorder. On an intravenous urogram following cardioangiography, the left kidney was noted to be displaced downwards (Fig. 1). A left supra-renal mass was strongly considered and further investigation initiated. The relevant examination included a hyperactive child with gross motor and mental retardation. He had a peculiar facies with hypertelorism, bilateral ptosis, increased epicanthal folds, high arched palate and frontal bossing. A loud systolic murmur was heard along the left sternal border. There was a left abdominal mass on deep palpation. The tips of the toes were hypopiastic, especially the 5th, bilaterally. This was confirmed on radiographs (Fig. 2). Fetal dilantin syndrome with associated neuroblastoma and ventricular septal defect was diagnosed. A chest film showed an elevated right hemidiaphragm due to an eventration (Fig. 3). The urine vanilyl mandelic acid level was normal; the ultrasonogram outlined a solid mass. A skeletal survey
993
a positive diagnosis. In retrospect, the ultrasound features are characteristic.
COMMENT
To make the diagnosis of a calculus in the common bile duct at an ultrasound examination it is necessary to show the calculus within the duct, which is often possible (Fig. 4). The Mirizzi syndrome is uncommon and the author was not fully aware of its features. With this knowledge, and applying strict ultrasound criteria, it should be possible to make
REFERENCES CLEMETT, A. R., and LOWMAN, R. M., 1965. The Roentgen
features of the Mirizzi syndrome. American Journal of Radiology, 94, 480-483. DEWBURY, K. C , JOSEPH, A. E. A., HAYES, S., and MURRAY,
C , 1979. Ultrasound in the evaluation and diagnosis of jaundice. British Journal of Radiology, 52, 276-280.
Lipomatous tumour of the uterus: radiographic and ultrasonic appearance By L Murray Houser, M.D., C. H. Carrasco, M.D. and C. R. Sheehan, Jr., R.D.M.S. Department of Radiology, Pennsylvania Hospital, 8th and Spruce Streets, Philadelphia, Pennsylvania 19107 (Received March 1979)
Masses in the pelvis that are shown to contain fat on X-ray are usually thought to be ovarian in origin. An unusual lipomatous tumour of the uterus, seen on plain radiographs and on ultrasound, is presented. This is the first report of the pre-operative demonstration of such a tumour by X-ray or ultrasound.
and smooth muscle tissue. Most patients are postmenopausal, predominantly in their 50's and 60's although one was 23 years old. The size of the tumours vary from several millimetres to 32 cm in diameter. They may occur anywhere within the uterus, but are however, predominantly found in the corpus. Most are associated with ordinary fibroids. Grossly, they are rounded or oval and well encapsulated. The pure lipomas are soft and yellow, while the more fibrous tumours tend to be lighter in colour and firmer. Clinically, the symptoms are indistinguishable from those of ordinary fibroids. Histologically, the pure lipomas consist of mature fat cells in a spare connective tissue stroma. The
CASE REPORT
A 59-year-old white female was admitted for evaluation of a pelvic mass. She had been in good health until four days prior to admission when she noted pain in her right hip and a sensation of pressure in her pelvis. Physical examination revealed a large, hard, irregular pelvic mass extending upward to the level of the umbilicus. On the plain film of the abdomen there was a rounded mass in the pelvis measuring approximately 18 cm in diameter. The central portion of this was radiolucent and surrounded by a relatively uniform soft tissue density measuring 1—2 cm in thickness (Fig. 1). Abdominal ultrasound demonstrated a 16 cm mass with a strongly echogenic central portion, which was surrounded by a relatively echo-free' border (Fig. 2). The central portion of the mass was so attenuating that the back wall could not be seen. The radiographic and ultrasonic findings were interpreted as a soft-tissue pelvic mass with a fatty central core and assumed to represent a dermoid tumour of the ovary. At operation, the mass was found to be within the uterus and was thought to be a fibroid tumour. Total hysterectomy was performed. Gross examination of the uterus showed a large, spherical, firm mass, which on cut section was seen to be within the myometrium. It was well circumscribed and yellowish in colour. Microscopically, the tumour was composed predominantly of mature fat cells with some interposed fibrous elements and smooth muscle. The pathologic diagnosis was fibromyolipoma of the uterus. DISCUSSION
Lipomatous tumours of the uterus are relatively uncommon. Salm (1973) found seven cases 5200 speciments over a 25 year period, an incidence of 0.14%. Brandfass and Everts-Suarez (1955) summarized the world literature in a comprehensive review. They found 33 pure lipomas and 63 mixed tumours (fibromyolipomas, myolipomas and fibrolipomas) with varying amounts of fibrous
FIG.1.
Radiolucent central mass corresponds to fatty tumour. A thin rim of more radiodense material, representing the myometrium, surrounds it.
992
1979, British Journal of Radiology, 52, 993-995
DECEMBER 1979
Case reports
theories are that they arise from: (1) misplaced embryonic fat cells in the uterus, or (2) fatty metaplasia of muscle or connective tissue cells. The recognition of fatty tumours by virtue of their relative radiolucence on standard radiographs is well known. Behan and Kazam (1978) have described the ultrasonic characteristics of fatty tissues and tumours in multiple locations throughout the body. They found that in the majority of instances fat is strongly echogenic and may cast an acoustic shadow preventing the demonstration of the entire mass, as in this case. Only rarely do fatty tumours appear echo-free. While in most instances a tumour of the pelvis which is seen to be composed of fatty tissue by either X-ray or ultrasound will be of ovarian origin, a lipomatous tumour of the uterus FIG. 2. should be considered. This is the first reported case Transverse supine B-scan 6 cm above the symphysis. The of a fatty tumour of the uterus being demonstrated strongly echogenic mass (black arrows) corresponds to the fatty tumour. Note how sound is absorbed, producing a on X-ray and ultrasound.
shadow and obscuring the back wall. The narrow, relatively sonolucent rim (white arrows) corresponds to the myometrium around the tumour.
REFERENCES BEHAN, M. and KAZAM, E., 1978. The echographic charac-
teristics of fatty tissues and tumors. Radiology, 129, 143-151. BRANDFASS, R. T. and EVERTS-SUAREZ, E. A., 1955. Lipo-
mixed type of fatty tumour has varying degrees of fibrous stroma and muscle tissue. The histogenesis of these tumours is uncertain. The two most popular
matous tumors of the uterus. American Journal of Obstetrics and Gynecology, 70, 359-367. SALM, R., 1973. The histogenesis of uterine lipomas. Beitrdge zur Pathologie der Verdauungsorgane, 149, 284—292.
Neuroblastoma in a child with the hydantoin and fetal alcohol syndrome. The radiographic features By J. Ramilo, M.D., and Vivian J. Harris, M.D. Department of Pediatric Radiology, Cook County Children's Hospital, Chicago, USA (Received April 1979 and in revised form June 1979)
Fetal alcohol and fetal dilantin (hydantoin) syndromes have been recognized only recently. Both have distinguishing features mainly characterized by peculiar facies, cardiovascular disorders, psychomotor retardation, limbs and skeletal anomalies (Jones et al, 1973; Hanson et al, 1976; Meadows, 1968; Hill et al, 1974; Goodman et al, 1976; Dabee et al, 1975). The association of malignant tumours in children with fetal alcohol or fetal dilantin syndrome has been documented, although rarely (Hornstein et al, 1977; Blattner et al, 1977). Only two previous cases of neuroblastoma associated with fetal hydantoJn syndrome have been reported (Pendergrass and Hanson, 1976; Sherman and Poizen, 1976). We are reporting a third case born to a mother who was alcoholic and taking diphenylhydantoin for a seizure disorder.
CASE REPORT
A 35-month-old child was admitted to Cook County Children's Hospital for investigation of his cardiac murmur and failure to thrive. His mother was an alcoholic and had been taking diphenylhydantoin sodium (Dilantin) for seizure disorder. On an intravenous urogram following cardioangiography, the left kidney was noted to be displaced downwards (Fig. 1). A left supra-renal mass was strongly considered and further investigation initiated. The relevant examination included a hyperactive child with gross motor and mental retardation. He had a peculiar facies with hypertelorism, bilateral ptosis, increased epicanthal folds, high arched palate and frontal bossing. A loud systolic murmur was heard along the left sternal border. There was a left abdominal mass on deep palpation. The tips of the toes were hypopiastic, especially the 5th, bilaterally. This was confirmed on radiographs (Fig. 2). Fetal dilantin syndrome with associated neuroblastoma and ventricular septal defect was diagnosed. A chest film showed an elevated right hemidiaphragm due to an eventration (Fig. 3). The urine vanilyl mandelic acid level was normal; the ultrasonogram outlined a solid mass. A skeletal survey
993
