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Taiwanese Journal of Obstetrics and Gynecology

HANYANG Repository

Laparoscopic treatment of Castleman&rsquo;s disease in a patient with a history of malignant Brenner tumor.

Laparoscopic treatment of Castleman&#39;s disease in a patient with a history of malignant Brenner tumor

Laparoscopic treatment of Castleman&#39;s disease in a patient with a history of malignant Brenner tumor.

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Taiwanese Journal of Obstetrics & Gynecology 55 (2016) 754e756Contents lists avaiTaiwanese Journal of Obstetrics & Gynecology
journal homepage: www.t jog-onl ine.comResearch LetterLaparoscopic treatment of Castleman's disease in a patient with a
history of malignant Brenner tumor
Won Moo Lee a, Joong Sub Choi a, Jaeman Bae a, *, Un Suk Jung a, Bo-kyeong Kang b
a Division of Gynecologic Oncology and Gynecologic Minimally Invasive Surgery, Department of Obstetrics and Gynecology, Hanyang University College of
Medicine, Seoul, South Korea
b Department of Radiology, Hanyang University College of Medicine, Seoul, South Koreaa r t i c l e i n f oArticle history:
Accepted 15 June 2015Dear Editor,
Castleman's disease (CD) is a rare, atypical, lymphoproliferative
disease of unknown etiology. The most common location for CD is
the mediastinum (63%) [1]. A retroperitoneal location has been
reported in 7% of patients, with only 2% of cases involving the
pararenal region [2]. For this reason, CD located in the retro-
peritoneum is difﬁcult to differentiate from other benign or ma-
lignant lesions. Here, we report a patient with CD located in the
anterior lower pole of the right kidney who had been diagnosed
with a malignant Brenner tumor after hysterectomy.
A 56-year-oldwoman visited our hospital with a chief complaint
of a growing abnormal retroperitoneal mass. She had undergone a
total abdominal hysterectomy (TAH) and bilateral salpingo-
oophorectomy (BSO) due to a malignant Brenner tumor at
another university hospital 3 months previously. Baseline serum
levels of CA-125 and CA 19-9 were normal (5.59 U/mL and 8.11 U/
mL, respectively). An abdominal computed tomography (ACT) scan
revealed a 3.0-cm nodule in the anterior lower pole of the right
kidney that had been visualized by ACT prior to the TAH and BSO.
The mass had increased in size over the course of 3 months
(Figure 1). No distant metastases or other abnormal ﬁndings were
noted on ACT. We suspected that the mass was a metastatic lymph
node and performed laparoscopic retroperitoneal removal.
The patient was placed in the dorsolithotomy position, and four
ports were used for the procedure (Figure 2). The ﬁrst assistant
gradually rotated the telescope 180 clockwise from the pelvic* Corresponding author. Department of Obstetrics and Gynecology, Medical
College of Hanyang University, 222 Wangsimni-ro, Seongdong-gu, Seoul 133-791,
South Korea.
E-mail address: obgybae@hanyang.ac.kr (J. Bae).
http://dx.doi.org/10.1016/j.tjog.2015.06.017
1028-4559/Copyright © 2016, Taiwan Association of Obstetrics & Gynecology. Published
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
Downloaded for Anonymous User (n/a) at Hanyang University - 
For personal use only. No other uses without permissiocavity toward the upper abdominal cavity during the procedure to
allow observation of the same direction on the monitor as that
viewed by the surgeon during the laparotomy. The retroperitoneal
space was entered after washing cytology. Initially, we pushed
aside the small intestine and mesentery to the left and inferior
direction, followed by lifting of the transverse colon using atrau-
matic forceps. After performing a transverse mesocolon incision
along the right side of the inferior vena cava and entering the lower
pole of the right kidney, we discovered an oval-shaped mass
(Figure 3). The mass was carefully dissected to avoid the ileocolic
vessels, and the feeding vessels arising from the aorta were clipped
using Hem-o-Lok clips (Telefex Medical, Wayne, PA, USA). The tu-
mor was delivered through a 10-mm port with an Endopouch
(Ethicon, Somerville, NJ, USA). Histopathologic evaluation revealed
unicentric, hyaline vascular-type CD (U-HVCD; Figure 4). The
washing cytology specimens revealed no malignant cells. Post-
operative recovery was uneventful, and the patient was discharged
on the 3rd postoperative day. After 55months, there continues to be
no disease recurrence.
Many investigators proposed possible CD etiologies, but none of
the suggestions have been proven. The low incidence of CD is
responsible for the incomplete understanding of the disease, with
current knowledge based largely upon case reports and histo-
pathologic reviews. CD exists in two histologic forms: a HVCD and a
plasma-cell-type CD (PCCD). Clinically, the two types were
described as unicentric (localized) and multicentric types. Most
cases of CD (70%) are U-HVCD, with younger patients usually pre-
senting with isolated benign asymptomatic lymphadenopathies
[3]. Unlike U-HVCD, most patients with PCCD have symptoms, such
as fever, diaphoresis, weight loss, night sweats, and fatigue [4].
When CD occurs in the retroperitoneal space, it is important to
distinguish it from other retroperitoneal masses. Differential di-
agnoses include benign neoplasms, lymphomas, sarcomas, neural
tumors, and metastatic lymph nodes. Although the radiographic
ﬁndings of CD are nonspeciﬁc, contrast-enhanced CT generally re-
veals a homogeneous, well-deﬁned, localized abdominal mass,
with enhancement probably due to the extensive vascularization
[5]. On magnetic resonance imaging (MRI), the mass exhibits low
signal intensity on T1-weighted images and high signal intensity onby Elsevier Taiwan LLC. This is an open access article under the CC BY-NC-ND license
Seoul from ClinicalKey.com by Elsevier on February 19, 2019.
n. Copyright ©2019. Elsevier Inc. All rights reserved.
Figure 1. CT scans reveals a well-enhanced 3-cm mass in the anterior lower pole of the
right kidney. This nodule was a homogenous solid mass with eccentric calciﬁcations.
(A) Pre-operative CT before total abdominal hysterectomy and bilateral salpingo-
oophorectomy at another university hospital. (B) Axial contrast-enhanced CT shows
a homogeneous retroperitoneal soft-tissue mass (blue arrow) displacing the pan-
creaticoduodenal vessel (white arrow) anteriorly. CT ¼ computed tomography.
Figure 2. Intra-operative position and arrangement of the trocar and instruments.
Figure 3. Intra-operative view of the tumor and surrounding structure after a trans-
verse mesocolon incision (broken line represents the incision site). IVC ¼ Inferior vena
cava.
W.M. Lee et al. / Taiwanese Journal of Obstetrics & Gynecology 55 (2016) 754e756 755T2-weighted images [6]. A low apparent diffusion coefﬁcient
calculated from diffusion-weighted MRI can provide useful infor-
mation in the differential diagnosis of retroperitoneal masses [5].
Because F-18 ﬂuorodeoxyglucose positron-emission tomography/
computed tomography (FDG-PET/CT) ﬁndings are seldom reported
[7], the utility of FDG-PET/CT is uncertain. In this case, we used only
ACT, and it was very difﬁcult to predict CD, given the existence of no
speciﬁc ﬁndings of CD in ACT. The fact that the patient had had a
malignant Brenner tumor and a growing retroperitoneal mass
confused us regarding the correct diagnosis.
High tissue concentrations of interleukin (IL)-6 (normal range, <
4.0 pg/mL), positive immunostaining for cluster of differentiationDownloaded for Anonymous User (n/a) at Hanyang University - Seo
For personal use only. No other uses without permission. C20 through ﬁne-needle aspiration biopsy (FNAB), and measure-
ment of serum IL-6 levels may provide useful information for a
diagnosis of CD [8,9]. Therefore, to differentiate between CD and
other retroperitoneal masses, appropriate clinical ﬁndings, typical
radiologic features, and serum IL-6 levels should be considered.
When physicians are conﬁdent of the clinical diagnosis of CD, it can
be conﬁrmed by FNAB; however, when cases are suspected of being
malignant masses, such as lymphomas, FNAB is not recommended.
Although laparoscopic treatment of CD has only occasionally
been reported, laparoscopic treatment of CD by a gynecologist hasul from ClinicalKey.com by Elsevier on February 19, 2019.
opyright ©2019. Elsevier Inc. All rights reserved.
Figure 4. Hyaline vascular-type of Castleman's disease. Note the histopathologic
“onion skin” appearance. The follicle is surrounded by a broad mantle zone composed
of concentric rings of small lymphocytes. (H&E stain; 200). H&E ¼ hematoxylin and
eosin.
W.M. Lee et al. / Taiwanese Journal of Obstetrics & Gynecology 55 (2016) 754e756756not been previously described. Traditionally, many surgeons,
especially urologists, have used a lateral transabdominal approach
(LTA) or a posterior retroperitoneal approach (PRA). However, these
approaches are not practical for gynecologists. Another method is
the transumbilical approach, which suits gynecologists better than
LTA and PRA. In the dorsolithotomy or supine position, the medial
reﬂection of the colon causes a major problem for the lateral
peritoneal approach. By contrast, for the transmesocolic approach,
the blood vessels, such as the ileocolic and other feeding vessels
from the aorta, are a major concern, given the risk of massive
hemorrhage during surgery. However, the advantages of the
transmesocolic approach include minimal handling of the bowel
and restoration of the retroperitoneal anatomy after closing the
mesocolic window [3].Downloaded for Anonymous User (n/a) at Hanyang University - 
For personal use only. No other uses without permissioUnicentric CD is generally cured after resection of the affected
lymph nodes, and the prognosis is favorable. However, multicentric
CD may be chronic, with remissions and exacerbations requiring
continuous therapy and a reportedmedian survival of 5e19months
[10]. Patient with unicentric disease should undergo an additional
radiologic evaluation 6e12 months after treatment to conﬁrm no
recurrence, and for patients with multicentric disease, close follow-
up and periodic surveillance are necessary to detect concurrent or
ensuing malignant lesions [3].
In conclusion, although a correct pre-operative diagnosis was
not made in our case, unicentric CD should be considered in the
differential diagnosis of retroperitoneal masses when they present
in an appropriate clinical setting and present typical radiographic
features. If a correct diagnosis of retroperitoneal unicentric CD,
including pararenal lesions, is established, the patient can be
managed safely by laparoscopy using a transmesocolic approach.
Conﬂicts of interest
The authors have no conﬂicts of interest relevant to this article.
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http://repository.hanyang.ac.kr/handle/20.500.11754/99045

Laparoscopic treatment of Castleman's disease in a patient with a history of malignant Brenner tumor

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Laparoscopic treatment of Castleman&#39;s disease in a patient with a history of malignant Brenner tumor

Abstract

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Full text

Available Versions

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HANYANG Repository

HANYANG Repository

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Laparoscopic treatment of Castleman's disease in a patient with a history of malignant Brenner tumor