Giant haemophilic pseudotumour of the pelvis: case report and literature review

Surgical treatment for pelvic haemophilic pseudotumour: a retrospective analysis of 21 cases

Background

Due to the rarity of pelvic haemophilic pseudotumour (PHPT) and demanding surgical technique for PHPT excision, no study reports the mid-term follow-up outcomes of surgical treatment of PHPT in a relatively large cohort. PHPT with varying degrees of bony pelvic involvement and infection status necessitates different operative procedures, yet there is currently no classification system for PHPT based on surgical practice.

Methods

The study was conducted between June 25, 2004 and July 18, 2023, in Peking Union Medical College Hospital and Nanfang Hospital in China. We performed a retrospective analysis involving 21 patients with 24 PHPTs with a mean follow-up period of 7.1 years. The demographic information, PHPT characteristics, surgical data, and perioperative complications were analysed.

Findings

21 consecutive male patients with 24 PHPTs (21 primary PHPTs and three recurrent PHPTs) that underwent surgical treatment were involved in the study. A classification system including four subtypes was introduced as (I) PHPT confined to soft tissue; (II) PHPT involving bony pelvic without pelvic discontinuity; (III) PHPT causing pelvic discontinuity; (IV) Infectious PHPT. Of the 24 PHPTs, 11 (45.8%) were identified as Type I, five (20.8%) as Type II, three (12.5%) as Type III, and five (20.8%) as Type IV. At the time of surgery, the patients had a mean age of 37.0 ± 9.5 years (Range, 24-52 years). The mean maximum diameter of PHPTs upon surgery was 17.0 ± 7.7 cm (Range, 4.3-40.0 cm). The mean surgical duration was 192 ± 77 min (Range, 60-330 min) and the median intraoperative blood loss was 400 mL (IQR, 225-950 mL, Range, 100-3000 mL). One patient (4.8%) underwent intraoperative cardiopulmonary arrest and expired the following week. Four PHPTs (16.7%) presented postoperative wound infections and poor wound healing. During the follow-up period, five PHPTs (20.8%) experienced pseudotumour recurrence.

Interpretation

Our findings suggest that surgical treatment for PHPTs is feasible and relatively safe. Symptomatic and progressive PHPTs should undergo surgical intervention as early as possible to minimise the surgical risks. Intraoperative use of abundant gelatin sponges in PHPT excision draws attention to severe embolism complications.

Funding

There are no sources of funding for this manuscript.

Management of abdominal pseudotumours in haemophilia: a systematic review

AIM

Haemophilic pseudotumours are complications in patients with haemophilia A or B and result from locally repetitive bleeding, mainly in the musculoskeletal system. Abdominal haemophilic pseudotumours are exceptionally rare but may cause severe complications. This systematic review aimed to evaluate therapy strategies for symptomatic abdominal haemophilic pseudotumours.

METHODS

We systematically searched three databases (Medline [PubMed], Web of Science and EMBASE) for publications published between 1995 and 2023. Two reviewers independently selected the studies, extracted data and performed a quality assessment using the JBI critical appraisal checklist.

RESULTS

From a total of 1199 articles, 39 articles describing 41 cases were included for final analysis. Conservative or interventional treatment was performed in 12 cases. In eight cases, a step-up to surgical therapy after interventional treatment was indicated. Primary surgical therapy was performed in 21 cases. Failure to cure was documented in 50% (n = 6) of patients treated in the first group, with a mortality rate of 16.6% (n = 2). Interventional therapy with a step-up to surgery showed no morbidity or mortality. Primary surgical resection documented favourable results in 66.6% (n = 14), with failure to cure in 9.5% (n = 2) and a mortality rate of 14.3% (n = 3).

CONCLUSION

Primary surgical resection can be a first-line therapy for symptomatic, abdominal haemophilic pseudotumours, whereas preoperative embolisation could be used as a bridging therapy before surgery, especially in emergency settings. Diagnostic biopsy and percutaneous drainage should be avoided to prevent complications.

Outcome of Surgical Management of Hemophilic Pseudotumor: Review of 10 Cases from Single-Center

Objective

To evaluate the operative methods and clinical results of surgical treatment in a case series of 10 patients with hemophilic pseudotumors.

Methods

Ten patients with hemophilic pseudotumors who received surgical resection treatment in our hospital from October 2017 to June 2020 were retrospectively reviewed. All patients were hemophilia A (factor VIII deficiency).The age range was 20–51 years. Preoperative imaging examination revealed the size of irregular mass from 8.2 cm× 3.3 cm× 2.3 cm to 22.3 cm× 15.5 cm× 17.0 cm. With the supplementary of recombinant coagulation factor VIII, five cases received complete resection; one received resection and skin grafting; one received cytoreduction surgery as the pseudotumor closing to iliac vessel and nerve; three cases received complete resection and construction as bone destruction. The perioperative variables were recorded and all the patients were followed in the outpatient clinic. Clinical and radiological assessments were conducted.

Results

In these patients, the average intraoperative blood loss volume was 783.1 mL (range, 240–2100 mL). Six patients received blood transfusion during perioperative period. The average duration of surgery was 140.7 min (range, 110–240 min). All wounds healed smoothly and there was no infection or chronic sinus formation. The average length of hospital stay was 16.3 days (range, 12–25 days). There is no iatrogenic vascular nerve injury in our series. Complete follow‐up was performed in all patients. Mean follow‐up duration was 14.2 months (range, 6–26 months). One patient with pseudotumor in the thigh had a recurrence 1 year after operation, then secondary operation was performed. In three cases who received complete resection and construction, patient 8 obtained bone graft and late fixation. X‐ray examination showed bone formation in the lesion at the 2‐year follow‐ups after operation. Patient 9 underwent knee replacement, his left knee showed flexion deformity in preoparation. At the last follow‐up, range of motion was improved from 0° to 40° compared with preoperative status. Patient 10 had pseudotumor in the distal femur, received long bone graft and intramedullary nail fixation.

Conclusions

Surgical resection for hemophilic pseudotumors is an effective and safe method. The choice of surgical procedure must be individualized according to the localization and progress of pseudotumor.

Haemophilic Pelvic Pseudotumour: A New Surgical Option

Background: Haemophilia is an inherited coagulopathy caused by the absence or dysfunction of clotting factor VIII or IX. Clinical manifestations are generally secondary to recurrent bleeding episodes mainly in the musculoskeletal system. Bleeding symptoms appear early in life and, when the disease is severe (when plasma factor VIII or IX activity is <1% of normal), joint and muscle bleeding may occur spontaneously. A pseudotumour is a recurrent, chronic, encapsulated, slowly expanding, muscle hematoma. Haemophilic pseudotumour is a rare complication of haemophilia which occurs, as a condition either from repeated spontaneous bleeding or coming from a traumatic origin, in 1–2% of haemophilic patients. Case report: A 32-year-old man with severe haemophilia A referred to our Clinic with a massive right iliac wing pseudotumour complicated by Staphylococcus aureus superinfection and skin fistulisation. In this report we describe the medical management and surgical treatment by the adoption of a novel surgical technique which involves the use of a pedicle-screw and rod system (PSRS), a polyglycolic acid MESH and bone cement in order to build up an artificial ilium-like bony mass. This case report highlights the importance of interdisciplinary approach and the efficacy of eradicating surgery as treatment, especially in the case of large and long-lasting lesions.

Treatment of pelvic haemophilic pseudotumour: A retrospective study

BACKGROUND

The incidence of a pelvic haemophilic pseudotumour is very low and is rarely seen in the clinic. Due to the lack of clear treatment standards, patients often suffer from the condition over a protracted period. The aim of this retrospective study was to present our institutional experience in the treatment of pelvic haemophilic pseudotumours over the past 8 years.

METHODS

We retrospectively analysed patients with a pelvic haemophilic pseudotumour who were treated in the Nanfang hospital between February 2012 and December 2019. The type and severity of haemophilia, the presence of inhibitors, comorbidities, pseudotumour imaging data, treatment and follow-up results were recorded and analysed.

RESULTS

Pelvic pseudotumours were identified in seven patients with haemophilia. Three patients had severe haemophilia, three had moderate haemophilia, one had mild haemophilia and inhibitors were present in two patients. Transfusion-related infectious diseases were noted in three patients. Spontaneous rupture and infection of the pseudotumour occurred in five patients. In addition, five patients underwent surgical treatment, two of whom healed well, two patients suffered recurrence of the pseudotumour, and one patient developed a postoperative haematoma twice. Two patients were treated conservatively, one of whom was unable to walk because of progression of the disease, while the other died from severe bleeding and infection.

CONCLUSIONS

Once a pelvic haemophilic pseudotumour is diagnosed, surgical resection should be performed as soon as possible. A delay in diagnosis and suboptimal treatment may lead to complications of the pelvic haemophilic pseudotumour.

An Unusual Presentation of Hemophilia A: Pseudotumor of Distal End Radius-Masquerading as Giant Cell Tumor

Hemophilia is a coagulation defect caused by a functional or absolute deficiency of coagulation factors. Deficiency of factor VIII leads to hemophilia A; deficiency of factor IX causes hemophilia B. Pseudotumor may arise from hemorrhage into the muscle and within the subperiosteal space and can lead to destruction of the adjacent muscle, bone, nerves, and vessels. A 60-year-old man presented with the complaint of pain and swelling in right wrist. The patient consulted the general practitioner who misdiagnosed it as a case of giant cell tumor due to typical X-ray changes. Biopsy was done following which there was prolonged bleeding leading to worsening of clinical condition and the patient presented in our hospital with ulcerated swelling. Routine blood investigations were within normal limit. Prothrombin time was 12.1 seconds and activated partial thromboplastin time (aPTT) was 54.3 seconds. Raised aPTT led to suspicion of hemophilia, and factor VIII and IX levels were investigated. Factor IX level was within normal limit. Factor VIII level was 6.3%. The patient was managed conservatively. Factor VIII level was replaced according to standard protocol (40 IU/kg per dose thrice a week for 10 days). Daily dressing was done using tranexamic acid locally. Lesion healed completely in 6 months.