Herein, we report a case of a giant well-differentiated liposarcoma located subgluteally and extending into the pelvis through the obturator foramen, nearby the urinary bladder and rectum without causing functional disturbances. The tumor was removed simultaneously with transgluteal posterior and anterior transabdominal approach. Six months postoperatively, no clinical and radiological evidence of recurrence was observed

Asen Todorov

Elka Angelova

Georgi Georgiev

Luben  Stokov

Luben Lubenov Stokov

Panayot Kurtev

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Article— Giant pelvic well-differentiated liposarcoma Journal of The Bulgarian Orthopedic and Trauma Association, Vol.61/1-2024,                ISSN 2815-3715 34  Giant pelvic well-differentiated liposarcoma  Luben Stokov1, Asen Todorov2, Panayot Kurtev3, Elka Angelova3,  Georgi P. Georgiev4(), Luben L. Stokov5  1Clinic of Orthopedics and Traumatology, UMHAT “St. Anna”, Sofia, Bulgaria 2Hospital Lozenets, Sofia, Bulgaria 3National Oncology Hospital, Sofia, Bulgaria 4Department of Orthopedics and Traumatology, University Hospital “Queen Giovanna - ISUL”, Medical University of Sofia, Sofa, Bulgaria 5Clinic of Orthopedics and Traumatology, MHAT “St. Sofia”, Sofia, Bulgaria georgievgp@yahoo.com  DOI: https://doi.org/10.58542/jbota.v61i01.116  Abstract—Herein, we report a case of a giant well-differentiated liposarcoma located subgluteally and extending into the pelvis through the obturator foramen, nearby the urinary bladder and rectum without causing functional disturbances. The tumor was removed simultaneously with transgluteal posterior and anterior transabdominal approach. Six months postoperatively, no clinical and radiologi-cal evidence of recurrence was observed. Keywords—well-differentiated liposarcoma, pelvic region, surgery. 1 Introduction In orthopedic practice the most frequent soft tissue tumors are adipocytic1. Benign ones, as lipomas are well known in the literature2,3. They could only be conservatively observed, or in cases of entrapment of regional nerves, impeding extremity function or due to cosmetic reasons lipomas could be excised2,3. Sometimes, the expected preoper-atively tumor mases as lipomas, could be locally aggressive or atypical lipomatous tu-mor (ALT)/well-differentiated liposarcoma (WDL). ALT/WDL is described as a low-grade malignancy with minimal tendency for metastasis1,4. Nowadays, the term WDL is used for locations in the retroperitoneum, mediastinum, and deep pelvis, whereas the term ALT is used when affected extremities1. Close monitoring is advised due to the possibility of local recurrence or dedifferentiation1,4. MRI is the best imaging modality used preoperatively for diagnosis of soft tissue tumors5,6.   2. Case report  A 63-year-old female presented to our clinic with an abnormal tumor mass in the right gluteal region. The tumor formation was discovered 8 years ago, but significantly Article— Giant pelvic well-differentiated liposarcoma Journal of The Bulgarian Orthopedic and Trauma Association, Vol.61/1-2024,                ISSN 2815-3715 35  enlarged in the last year. The patient complains of discomfort and pain when sitting, lying, as well as when climbing. A hypoesthesia in the right lower limb was observed. Clinical examination revealed soft tissue mass in the right gluteal region measuring 10/8 cm. Contrast-enhanced CT and MRI reveal the passage of the tumor mass from gluteal region through the obturator foramen into the pelvic cavity, nearby to the urinary bladder and rectum, where it measures 10/7 cm (Figure 1).    Figure 1. a, b) Preoperative CT; c) Preoperative MRI. No functional abnormalities were detected in the kidneys, urinary bladder, or rectum. After preoperative planning, the patient underwent surgery using a posterior transglu-teal approach and an anterior transabdominal approach. Dissection was carried out be-tween the fibers of the gluteus maximus muscle towards the tumor mass, which was circumferentially mobilized. The sciatic nerve was released from partial compression, and the obturator foramen was reached (Figure 2).    Figure 2. a) Surgical approach; b) Intraoperative photography.  Article— Giant pelvic well-differentiated liposarcoma Journal of The Bulgarian Orthopedic and Trauma Association, Vol.61/1-2024,                ISSN 2815-3715 36  The wound was temporarily closed, and the patient was rotated from supine to prone gynecological position on the operating table. A midline abdominal incision provided access to the pelvis, where the tumor was meticulously dissected from the massive growths towards the surrounding neurovascular and soft tissue structures. The mobi-lized encapsulated tumor was pulled through the relatively narrow foramen (Figure 3 and 4).    Figure 3. a) Surgical approach; b,c: Intraoperative photography.   Figure 4. Macroscopic appearance.  There were no intraoperative complications, and the postoperative period was une-ventful, although sensory disturbances in the right lower limb persisted. The patient was verticalized on the next day after surgery. Postoperative MRI presented the full excision of the tumor (Figure 5). Article— Giant pelvic well-differentiated liposarcoma Journal of The Bulgarian Orthopedic and Trauma Association, Vol.61/1-2024,                ISSN 2815-3715 37    Figure 5. Postoperative MRI.  Histologically, the ALT/WDL was confirmed. Six months postoperatively, there were no clinical or imaging signs for recurrence.   3. Discussion and Conclusion  Jauffred et al.7 analyzed 35 patients with ALT that underwent marginal excision. Recurrences were observed in six of them (17%). Histologically dedifferentiated lipo-sarcoma was identified in three patients with recurrence of ALT. The authors recom-mend monitoring patients at different intervals.    4. References  1. Nagano S, Yokouchi M, Setoguchi T, Ishidou Y, Sasaki H, Shimada H, Komiya S. Dif-ferentiation of lipoma and atypical lipomatous tumor by a scoring system: implication of increased vascularity on pathogenesis of liposarcoma. BMC Musculoskelet Disord. 2015;16:36. doi: 10.1186/s12891-015-0491-8. 2. Georgiev GP, Telang M, Firoozi B, Ananiev J, Landzhov B, Olewnik Ł, Stokov L. Giant lipoma of the hand. Acta Medica Bulg. 2022;49(4):55-57. doi: 10.2478/AMB-2022-0043. Article— Giant pelvic well-differentiated liposarcoma Journal of The Bulgarian Orthopedic and Trauma Association, Vol.61/1-2024,                ISSN 2815-3715 38  3. Georgiev GP, Slavchev S, Stocov L. Giant lipoma around the proximal radial bone. Bulg J Orthop Traumatol. 2012:49(2):90-93. 4. Laurino L, Furlanetto A, Orvieto E, Dei Tos AP. Well-differentiated liposarcoma (atyp-ical lipomatous tumors). Semin Diagn Pathol. 2001 Nov;18(4):258-62. 5. Doyle AJ, Pang AK, Miller MV, French JG. Magnetic resonance imaging of lipoma and atypical lipomatous tumour/well-differentiated liposarcoma: observer performance using T1-weighted and fluid-sensitive MRI. J Med Imaging Radiat Oncol. 2008;52:44–8. doi: 10.1111/j.1440-1673.2007.01910.x. 6. Georgiev GP, Ananiev JM, Groudeva V. Squamous cell carcinoma of the thumb: A case report. Cureus. 2024;16(2): e54046. doi:10.7759/cureus.54046. 7. Jauffred SF, et al. Poster #1813. Intramuscular lipomas, atypical lipomatous tumors rarely recurred after resection. EFORT Congress; May 27-29, 2015; Prague.  Authors Luben Stokov, M.D., Ph.D. is a member of the Bulgarian Orthopedic and Trau-matology Association (BOTA). He works as an ortopaedic surgeon at Clinic of Or-thopedics and Traumatology, UMHAT “St. Anna”, Sofia, Bulgaria. He is professor at the Department of Orthopedics and Traumatology, Medical University of Sofia, Sofia, Bulgaria. He is a member of the Editorial Board of the Journal of the Bulgarian Ortho-paedics and Trauma Association (JBOTA). Asen Todorov, MD works as surgeon at the Clinic of Vascular Surgery, Hospital Lozenets, Sofia, Bulgaria. Panayot Kurtev, MD, PhD works as surgeon at the Clinic of General Surgery, Na-tional Oncology Hospital, Bulgaria. He is professor at the Clinic of General Surgery, National Oncology Hospital, Bulgaria. Elka Angelova, MD works as surgeon at the Clinic of General Surgery, National Oncology Hospital, Bulgaria. Georgi P. Georgiev, M.D., Ph.D., D.Sc. is member of the Bulgarian Orthopedic and Traumatology Association (BOTA). He works as an orthopaedic surgeon at the Department of Orthopedics and Traumatology, University Hospital “Queen Giovanna - ISUL”, Medical University of Sofia, Bulgaria. He is Assistant Professor at the De-partment of Orthopedics and Traumatology, Medical University of Sofia, Bulgaria. He is a member of the Editorial board of BMC Musculoskeletal Disorders and Clinical Anatomy. Luben Lubenov Stokov, is a member of the Bulgarian Orthopedic and Trauma-tology Association (BOTA). He works as volunteer at Clinic of Orthopedics and Trau-matology, MHAT “St. Sofia”, Sofia, Bulgaria. He is medical student, Medical Univer-sity of Sofia, Sofia, Bulgaria.  

Giant pelvic well-differentiated liposarcoma

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Giant pelvic well-differentiated liposarcoma

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