Sonographic Evaluation of a Pelvic Spindle Cell Neoplasm

Nicole Wolcott, RDMS

DMS 497 Clinical Practicum IV
Fall 2015

CERTIFICATE OF AUTHORSHIP: I certify that I am the author of this research paper. I

have cited all of the sources from which I used data, ideas, or words (quoted or paraphrased).
I also certify that this paper was prepared by me specifically for this course.
Signature: ________Nicole Wolcott_________

Date: ___December 28, 2015_____

Sonographic Evaluation of a Pelvic Spindle Cell Neoplasm

Abstract
Sonograms are valuable and noninvasive imaging examinations which are especially safe
because of their inability to expose patients to radiation. Though sonography is rarely utilized to
examine the gastrointestinal (GI) tract due to the fact that sound waves are incompatible with air,
when masses of the GI tract become large, they can be evaluated utilizing sonography.
Sonography is a valuable tool and is often used in conjunction with other imaging modalities. A
sonogram can visualize objects in real time as well as provide specific information pertaining to
the object in question. Some of the information sonograms are able to provide include
identifying location, size, and appearance of objects within the body as well as receiving specific
information relating to presence, amount, and velocity of blood flow. The objective of this paper
is to provide an example of a spindle cell neoplasm case and to demonstrate the utilization of
sonography in the detection and ensuing events that occurred with this neoplasm.

Key words
Spindle Cell, Gastrointestinal Stromal Tumor, Sonography, Neoplasm

Gastrointestinal stromal tumors (GIST) are the common mesenchymal tumor of the
gastrointestinal (GI) tract. Though they are rarely found within the pelvis, these neoplasms are
occasionally discovered to have grown inferiorly into the pelvic area and are documented to have
adhered to the organs of the pelvis. If large enough, these tumors can cause a mass effect on the
surrounding organs and surgery will be inevitable. This paper will discuss the case history,
sonographic findings, and diagnosis documented on a patient with a pelvic spindle cell neoplasm
originating from a gastrointestinal stromal tumor, as well as, give a brief overview of this type of
neoplasm.

Case Report
The patient was a thirty-two year old, African American, female. The patient was gravida 2, para
2. Caesarean sections were performed with both of the patients pregnancies and both were
completed without complication. The patient had a recurring history of symptomatic uterine
leiomyomas, menorrhagia, and anemia. Labs were taken on the patient and results came back
that her hematocrit was low. The low hematocrit could have been an indication of the patients
history of anemia. All other labs that would be pertinent to this examination were within normal
limits. The patient was admitted to have a hysterectomy performed due to her current and
recurring symptoms of menorrhagia, chronic pelvic pain, and symptomatic uterine leiomyomas.
During the attempted hysterectomy, a hypervascular pelvic mass was discovered. While in
surgery, the patient began to bleed beyond what the surgeons had prepared for due to the
hypervascularity of the mass. The attempted hysterectomy was abandoned due to the massive
amount of bleeding that occurred during the procedure. The patient was administered blood
while in recovery to restore the lost blood that occurred during the procedure.

The discovery of the pelvic mass warranted further investigation of the mass. The patient
received a number of imaging procedures for the purpose of exploring the possibilities of the
origin and type of pelvic mass which was present. Over the course of a period of ten months,
these procedures were carried out with similar findings reported on each of the various
examinations. On the computed tomography (CT) examinations, a large, hypervascular pelvic
mass was noted. (See figure 1) Also noted on CT were bilateral pleural effusions, bilateral
hydronephrosis, and ascites. Several magnetic resonance imaging (MRI) examinations were
performed which noted a large mass within the pelvis, the uterus and cervix displaced and
located within the mid abdomen, and the urinary bladder displaced superiorly and anteriorly to
the mass. Finally, an angiogram was performed and noted that there was complex anatomy to the
pelvic mass. Multiple ultrasounds were also performed throughout the ten months.
Sonographic Findings
Utilizing sonography, the mass was further evaluated. It was noted on the sonogram that the
mass appeared to be located within the patients pelvis, extending superiorly into the lower
abdomen. The mass was noted to have smooth, irregular borders. The mass appeared
heterogeneous with the majority of it appearing medium shades of gray; however, there were
other areas within the mass which appeared anechoic and other areas which appeared
hyperechoic. (See figure 2) The mass was measured to be 18.6 x 14.6 x 17.2 cm. When color
Doppler was applied, the mass appeared to be hypervascular throughout. (See figure 3) The mass
was so large it caused a mass effect on its surrounding structures. The mass was found to have
displaced the urinary bladder superiorly and anteriorly. The mass also displaced the uterus into
the right upper quadrant. Along with displacing several organs, the mass compressed the ureters
bilaterally. The compression of the ureters caused bilateral hydronephrosis to occur within the

kidneys. The right kidney was discovered to have moderate hydronephrosis and the left kidney
presented slightly more effected with severe hydronephrosis noted within the kidney. The
hydronephrosis was attempted to be corrected with the placement of bilateral nephrostomy tubes;
however, the mass still caused such a compression on the ureters and nephrostomy tubes, that the
hydronephrosis was still present even after the placement of these tubes. Both nephrostomy tubes
were noted on the ultrasound and appeared to be parallel, echogenic linear structures entering the
hilum of each kidney. (See figure 4) Ascites was also noted on ultrasound as anechoic areas of
fluid surrounding the abdominal organs.
Discussion
After discovering the pelvic neoplasm during surgery and following the progression of the mass
over a period of ten months, the doctors decided it was in the patients best interest to have the
mass removed. The patient was sent to surgery and had a pelvic exeneration performed. A pelvic
exeneration is a surgery in which an en bloc tumor resection of the pelvic structures is
performed. Pelvic structures to be removed in this type of resection include the uterus, cervix,
bladder, and rectum.1 During the surgery, it was discovered that the mass had attached to the
surrounding organs via fibrous adhesions. It would have been impractical to only remove the
fibrous adhesions from the surrounding organs, so the surgeons decided to simultaneously
remove the other pelvic structures noted above. Due to the number of vital organs that had to be
removed during the surgery, a sigmoidostomy and ileal conduit were created. Bleeding during
the operation was significant given the vascular nature of the mass. It was estimated that the
patient lost 20 units of blood during the surgery. The patient was noted to be in stable condition
immediately following the surgery and blood was once again administered to the patient.

Specimens of the tumor were sent off to be examined and came back with results that the
tumor was a pelvic spindle cell neoplasm. The neoplasm was a gastrointestinal tumor (GIST)
originating from the small intestine. GISTs are abnormal cells which form in the connective
tissues of the GI tract. They can vary in size from 1 to 40 cm and are mostly composed of spindle
cells, such as the neoplasm in this particular case.2 These neoplasms are the most common
mesenchymal tumor of the GI tract and most commonly arise from the stomach but may also
arise from the small intestines, where this particular neoplasm was found to be originated from.2 3
When small in size, GISTs are normally asymptomatic and found incidentally. However, when
these tumors increase in size over time, they become more symptomatic with common symptoms
including abdominal or pelvic pain and, less frequently, anemia, menorrhagia, or hemorrhage.2 4
Common clinical appearances of GISTs vary depending primarily on their size. When they are
small they tend to appear as homogeneous medium shades of gray. However, when these tumors
become larger, they tend to appear more heterogenous with levels of gray ranging from anechoic
to hyperechoic. Typically, the anechoic areas represent necrosis of the mass while the
hyperechoic areas typically represent areas of calcifications.5 It has been predicted that if the
mass appears heterogeneous with irregular borders and is larger than 3cm, that there is a higher
risk for malignancy.4 It is rare for this type of tumor to spread to other organs via the metastatic
route; however, these tumors often adhere to other organs via fibrous adhesions.
Conclusion
In conclusion, there are several similar cases that have been reported throughout literature. When
compared to other similar cases, the mass appeared similarly in echotexture and shape. It also
presented similarly symptomatically with the symptoms of pelvic pain, menorrhagia, and
anemia. Although the mass described in this case matched the qualifications for a mass which are

at a higher risk for malignancy, the pathology report determined that this mass was actually
benign. This case is proof that ultrasound is a very valuable imaging modality. Though other
imaging modalities besides ultrasound are typically utilized to view GI lesions due to the
presence of bowel and gas which make it difficult to visualize the lower abdomen and pelvic
area, if a mass is large enough, ultrasound can readily visualize masses of the GI tract as was
noted in this case. It is common for this type of neoplasm to be followed up with surgery as it
was in this case. It is always important for sonographers to thoroughly document any abnormal
finding when completing a sonogram. In the case of a GIST, the sonographer should make sure
to document the location and size of the mass over time to see if there is any growth of the mass.
It is also important to note the effect on the surrounding organs that the mass might be creating.
Finally, a sonographer would need to document blood flow in the mass by placing color Doppler
on the mass and, if blood flow was seen, also placing spectral Doppler on the mass in order to
obtain the velocities of blood flow within the mass.

Reference Page
1. Teng, N. Pelvic Exenteration: Overview, Preparation, Technique. Medscape. 2013.
Available at: http://emedicine.medscape.com/article/1833913-overview. Accessed 2015.
2. Castelguidone, Ede Ldi. GISTs-- Gastrointestinal stromal tumors. Milano: Springer;
2011.
3. Bisset RAL. Differential Diagnosis In Abdominal Ultrasound. 3rd ed. New Delhi:
Elsevier India; 2008:210.
4. Maconi G. Carcinoid and Submucosal Tumors. In: Ultrasound Of the Gastrointestinal
Tract. Second. Springer; 2014:197.
5. Middleton WD. General And Vascular Ultrasound Case Review. 2nd ed. Philadelphia,
Pa: Mosby Elsevier; 2007:151.

Spindle Cell
Neoplasm

Figure 1: Computed Tomography image demonstrating a sagittal cut of the heterogenous

neoplasm.

Figure 2: Sagittal image of the heterogenous neoplasm demonstrating both anechoic and
hyperechoic spaces within the mass. This image also demonstrates measurements in two planes.

Figure 3: Color Doppler image of the neoplasm demonstrating hypervascular blood flow
throughout.

Nephrostomy Tube

Hydronephrosis within
the renal pelvis

Figure 4: Sagittal image of the right kidney demonstrating mild hydronephrosis and renal stent
running through the right ureter and entering into the renal hilum.