Journal of

Case Reports and Images in Surgery

 
     
Clinical Image
 
Sempre fidelis: A pain in the neck and abdomen
Hiang Jin Tan1, Hsien Tsung Tay2, Chung Yip Chan3
1MD, MRCS, Medical Officer, Department of General Surgery, Singapore General Hospital, Singapore.
2MBBS, MRCS, Associate Consultant, Department of General Surgery, Singapore General Hospital, Singapore.
3MBBS, M Med (Surg), FRCSEd (Gen), Senior Consultant, Department of Hepato-pancreato-biliary and Transplant Surgery, Singapore General Hospital, Singapore.

Article ID: 100039Z12HT2017
doi:10.5348/Z12-2017-39-CL-4

Address correspondence to:
Hiang Jin Tan
MOHH, 1 Maritime Square, #11-25 Harbourfront Centre
Singapore, 099253

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How to cite this article
Tan HJ, Tay HT, Chan CY. Sempre fidelis: A pain in the neck and abdomen. J Case Rep Images Surg 2017;2:14–16.


Case Report

A 66-year-old male was admitted with a compaints of right hypochondriac pain since one month. It was associated with loss of weight and appetite over the preceding six months. His past medical history included hypertension, hyperlipidemia and a left neck lump excision 25 years ago. Physical examination showed hepatomegaly but was otherwise normal. An ultrasound of abdomen revealed a heterogeneous liver mass which was further characterized with a computed tomography (CT) scan of the thorax, abdomen and pelvis which showed a highly vascular dominant hepatic mass in the right lobe (Figure 1). Lung nodules were also present in the right lower and left upper lobes. Liver enzymes, tumor markers and hepatitis markers were unremarkable. After discussion in multi-disciplinary meeting, decision was made for surgical resection as he would have long survival. He underwent staged resection of his pulmonary metastases followed-by a right hepatectomy. Findings were a large 18 cm tumor occupying the right lobe without involvement of segment 4 (Figure 2). He had an uncomplicated recovery and was discharged.

Histology returned metastatic, multifocal solitary fibrous tumors (SFT). There was spindle cell proliferation in vague whirls interjected by ecstatic vascular spaces with occasional hemangiopericytic pattern (Figure 3). The past medical history of left neck lump was of hemangiopericytoma treated by surgical excision and adjuvant radiotherapy. Histology for the pulmonary metastases returned solitary fibrous tumors as well.


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Figure 1: Computed tomography scan of the abdomen showing a highly vascular dominant hepatic mass in the right lobe possibly involving segment 4b.



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Figure 2: A large 18-cm tumor occupying the right lobe without involvement of segment 4.



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Figure 3: Spindled cells with vesicular chromatin, inconspicuous nucleoli and intervening collagen bundles.


Discussion

Hemangiopericytoma is a rare soft tissue tumor with low metastatic potential. Metastases can occur anywhere in the body with the most common sites of distant spread is being the lungs and liver [1]. We report a case of recurrence of hemangiopericytoma more than two decades after resection of the primary. Hemangiopericytoma is known for low tendency of recurrence and low metastatic potential after complete resection (10–15%) [2]. Recurrence can take many years to appear. As in this particular case, patient was already discharged from follow-up after surgical resection of neck lump 25 years ago. The incidence of this tumor is low and it accounts for <2% of all soft tissue sarcomas [3]. Metastases usually go unnoticed until sizeable enough to cause local symptoms. The main modality of diagnosis is CT scan. Characterizing features are a heterogeneous mass with avid and heterogeneous enhancement after intravenous contrast administration in most cases [4]. Surgery is the mainstay of treatment for resectable disease. Life-long follow-up is essential as recurrence is possible. We hope others will learn from our experience.


Conclusion

Hemangiopericytoma has long course of duration for recurrence. Hence, long-term surveillance is required to detect the recurrence.

Keywords: Hemangiopericytoma, Liver, Recurrence, Tumor


References
  1. Baldi GG, Stacchiotti S, Mauro V, et al. Solitary fibrous tumor of all sites: Outcome of late recurrences in 14 patients. Clin Sarcoma Res 2013 Apr 3;3:4.   [CrossRef]   [Pubmed]    Back to citation no. 1
  2. Magro G, Emmanuele C, Lopes M, Vallone G, Greco P. Solitary fibrous tumour of the kidney with sarcomatous overgrowth. Case report and review of the literature. APMIS 2008 Nov;116(11):1020–5.   [CrossRef]   [Pubmed]    Back to citation no. 2
  3. Cheung TT, Lo R, Poon RT. An unusual cause of epigastric pain. Gastroenterology 2013 May;144(5):e11–2.   [CrossRef]   [Pubmed]    Back to citation no. 3
  4. Wignall OJ, Moskovic EC, Thway K, Thomas JM. Solitary fibrous tumors of the soft tissues: Review of the imaging and clinical features with histopathologic correlation. AJR Am J Roentgenol 2010 Jul;195(1):W55–62.   [CrossRef]   [Pubmed]    Back to citation no. 4
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Author Contributions
Hiang Jin Tan – Substantial contributions to conception and design, Acquisition of data, Analysis and interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published
Hsien Tsung Tay – Substantial contributions to conception and design, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published
Chung Yip Chan – Substantial contributions to conception and design, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published
Guarantor of submission
The corresponding author is the guarantor of submission.
Source of support
None
Conflict of interest
Authors declare no conflict of interest.
Copyright
© 2017 Hiang Jin Tan et al. This article is distributed under the terms of Creative Commons Attribution License which permits unrestricted use, distribution and reproduction in any medium provided the original author(s) and original publisher are properly credited. Please see the copyright policy on the journal website for more information.



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