PELVIC LIPOMATOSIS ASSOCIATED WITH INVASIVE CYSTITIS GLANDULARIS

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PELVIC LIPOMATOSIS ASSOCIATED WITH INVASIVE CYSTITIS GLANDULARIS Powered By Docstoc
					Y.A T d
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KAD R Y.A LMEZ, A ATAY G           TULUNAY, F ANKARA MEDICAL SCHOOL
                            , ZDENJOURNAL OORHAN G                      Vo 2 , N 3 2 0
                                                                          l 4 o , 02                                        15
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                                                                                                                        155-158




   PELVIC LIPOMATOSIS ASSOCIATED WITH INVASIVE
               CYSTITIS GLANDULARIS

          Kadir Türkölmez* ✥ Çağatay Göğüş* ✥ Özden Tulunay** ✥ Orhan Göğüş*


                        SUMMARY                                                              ÖZET
    Pelvic lipomatosis is a rare entity with unknown eti-             İnvaziv Sistitis Glandularis ile Birliktelik Gösteren
  ology. It often is associated with chronic inflammatory                             Pelvik Lipomatozis
  changes or malignancies. We report herein a 56-year-old           Pelvik lipomatozis etyolojisi bilinmeyen ve nadir görü-
  man with pelvic lipomatosis associated with invasive            len bir antitedir. Pelvik lipomatozis sıklıkla kronik infla-
  cystitis glandularis causing severe urinary obstruction         matuar değişiklikler veya malinitelerle birliktedir. Bilate-
  with bilateral massive hydroureteronephrosis. The diag-         ral masif hidroüreteronefroz ile birlikte ciddi üriner obst-
  nostic procedure and the management of the patient are          rüksiyona yol açan invaziv sistitis glandülaris ile birlikte
  described.                                                      pelvil lipomatozisli 56 yaşında bir erkek hastayı sunmak-
   Key Words: Cystitis Glandularis, Pelvic Lipomatosis,           tayız. Hastanın tedavisi ve tanısal prosedür tarif edilmek-
  Nuclear Magnetic Resonance.                                     tedir.
                                                                    Anahtar Kelimeler: Sistitis Glandularis, Pelvik Lipoma-
                                                                  tozis, Nükleer Magnetik Rezonans




    Pelvic lipomatosis is characterized by the pro-                CASE REPORT
liferation of infiltrating fatty tissue in the bony
                                                                    A 56 year-old man presented with hematuria,
pelvis. This entity was first described by Engels in
                                                                dysuria, frequency, stranguria and lower abdomi-
1959 (1). The etiology of pelvic lipomatosis is
                                                                nal pain with radiation to the bilateral lomber re-
unclear. Computerized tomography (CT) has be-
                                                                gion for 4 months. Physical examination was nor-
en used in diagnosis of pelvic lipomatosis. Nuc-
lear magnetic resonance seems to be supported                   mal. Urine analysis showed numerous red blood
to diagnosis of pelvic lipomatosis. The incidence               and white blood cells. Urine culture and strain
of proliferative cystitis in patients with pelvic li-           for Mycobacterium tuberculosis were negative.
pomatosis is high. There also may be an incre-                  Serum urea, creation and lipid profile were nor-
ased risk of upper urinary tract obstruction, uro-              mal. Excretory urography (IVP) revealed bilateral
lithiasis and adenocarcinoma of the bladder. We                 high-grade hydroureteronephrosis with an irregu-
present nuclear magnetic resonance image of pa-                 lar filling defect in bladder base (Fig. 1). Transrec-
tient who has pelvic lipomatosis associated with                tal ultrasonography confirmed a diffuse irregular
invasive cystitis glandularis is one of the few ca-             and infiltrative mass in the bladder base. Compu-
ses.                                                            terized tomography (CT) demonstrated the pre-



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* Ankara University, School of Medicine, Department of Urology, Ankara.
** Ankara University, School of Medicine, Department of Pathology, Ankara.
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Received: Sep 05, 2001                            Accepted: Oct 09, 2001
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                                                       PELVIC LIPOMATO I ASSOCIATED WITH INFASIVE CYSTITIS GLANDULARIS




                                                           Figure 2: Nuclear magnetic resonance imaging
                                                          in T1 weighted image shows bladder tumor with
                                                          invasion of the prostate and abundant perivesical
                                                                          fatty tissue (arrow).




    Figure 1: Excretory urogram reveals bilateral
                                                       perivesical fatty tissue and the prostate was inva-
 hydroureteronephrosis and filling defect in bladder
                                                       ded. The tumor demonstrated cystitis glandularis
                        base.
                                                       with metaplastic intestinal epithelium (Fig.3).
                                                       Convalescence was uneventful.
                                                           DISCUSSION
sence invasive bladder tumor. Nuclear magnetic
                                                           Pelvic lipomatosis is a rare condition by diffu-
resonance (NMR) scan of the pelvis demonstrated
                                                       se infiltrating fatty tissue in the true pelvis. In
invasive bladder tumor with abundant perivesical
                                                       1959, Engles reported a case with pelvic lipoma-
fatty tissue (Fig. 2). Cystoscopy confirmed signifi-
                                                       tosis (1).The pathological entity of pelvic lipoma-
cant small bladder capacity and diffuse bullous
edema associated with 5x4 cm solid tumor in the
bladder base. Multiple biopsies were obtained.
Histologic examination of the biopsies revealed a
cystitis glandularis with intestinal metaplasia.
There was no vesicoureteral reflux (VUR) on vo-
iding cystourethrography (VCUG). Urodynamic
evaluation showed hypocompliance and small
total bladder capacity (62 cc). We performed bi-
lateral percutaneous nephrostomy for a few we-
eks. Cystoprostatectomy and ileal conduit urinary
diversion were performed. At laparatomy, true
pelvis was narrowed by the abundant adipose tis-
sue. Macroscopically, the cystoprostatectomy            Figure 3: Cystoprostatectomy specimen demonstrates
specimen was covered by excessive fatty tissue.         Brunner’s nest (Right), mucoid and intestinal metap-
On histologic examination, a 5x4 cm solid tumor         lastic epithelium in central submucosal glands and a
was located on the trigone and extended to the                      Goblet cell (arrow). H&E, X50.
KAD R T RK LMEZ, A ATAY G   , ZDEN TULUNAY, ORHAN G                                                      5
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tosis still remains somewhat of enigma as can be        and De Kock evaluated NMR image of a patient
witnessed by the variety of clinical presentations,     with pelvic lipomatosis. They suggested that the
radiological findings and various treatments for        diagnosis of pelvic lipomatosis may be supported
the disease. Proliferative cystitis has been obser-     by a NMR scan of the pelvis (4). NMR image not
ved in most patients with pelvic lipomatosis. The       only allows diagnostic confirmation comparable
reason for the high incidence of proliferative
                                                        to that possible with CT but also provides deline-
cystitis in pelvic lipomatosis remains unclear. It is
                                                        ation of cephalad displacement of the bladder ba-
speculated that the associated chronic inflamma-
                                                        se, elongation of the bladder neck and posterior
tory changes in the bladder may be a result of
lymphatic obstruction created by the pelvic fat         urethra, and elevation of the prostate gland. The
proliferation (2).                                      MR images show characteristic medial and supe-
                                                        rior displacement of the seminal vesicles and
    Proliferative cystitis may be associated with
                                                        show fatty tissue separating the prostate gland
adenocarcinoma of the bladder. Particularly, an
                                                        from the rectum.
adenomatous proliferation of cystitis glandularis
is premalignant. Heyns et al reported a patients             The present case is one of a few in which the
with pelvic lipomatosis in whom adenocarcino-           disease has pelvic lipomatosis associated with in-
ma of the bladder developed 6 years after a diag-       vasive (perivesical and prostatic invasion) cystitis
nosis of proliferative cystitis (3).                    glandularis. Nuclear magnetic resonance ima-
   Computerized tomography (CT) has been                ging is useful diagnostic tool in pelvic lipomato-
used in diagnosis of pelvic lipomatosis. Allen          sis.
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                                                          PELVIC LIPOMATO I ASSOCIATED WITH INFASIVE CYSTITIS GLANDULARIS




REFERENCES

1. Engles EP: Sigmoid colon and urinary bladder in        3. Heyns CF, De Kock MLS, Kırsten PH and Van Vel-
   high fixation; roentgen changes simulating pelvic         den DJJ: Pelvic lipomatosis associated with cystitis
   tumor. Radiology; 72, 419, 1959                           glandularis and adenocarcinoma of the bladder. J
                                                             Urol, 145; 364-366, 1991
2. Yalla SV, Ivker M, Burros HM and Doley F: Cystitis
   glandularis with perivesical lipomatosis, frequent     4. Allen FJ, and De Kock MLS: Pelvic lipomatosis: The
   association of two unusual proliferative conditions.      nuclear magnetic resonance appearance and as-
   Urology, 5; 383, 1975                                     sociated vesicoureteral reflux. J Urol, 138: 1228-
                                                             1230, 1987

				
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