1. Case Report
A 45-year-old G8p7 female patient, with no co-morbidities and no history of previous abdominal surgery, presented to the hospital with complaints of chronic abdominal pain for the last seven months that did not respond to analgesics. She complained also about intermittent mild vaginal bleeding that had not stopped after six months of hormonal therapy. Calcifying fibrous tumor (CFT) is a benign lesion characterized by its specific histological findings and is found as solitary or multiple lesions in several locations of the human body. A consent was obtained from the patient prior to performing this study. The Importance of the case comes from these lesions are intra and extra peritoneum in a healthy patient and do not suffer from any symptoms.
Ultrasound scan revealed amass in the pelvis near the uterus measured 3 to 4 cm (Figure 1). She underwent CT imaging which showed several calcifications distributed in the pelvis and the abdomen most of them measured 3 - 4 cm (Figure 2). The patient’s complete blood count and other routine biochemical values were within normal limits as follows:
WBC (6.9) 10 * 3/UL. HGB (13.4) g/dl. PLT (198)10 * 3/UL. GLC (110) mg/dl.
ALT (14) U/L. AS T (12) U/L. UREA (26) mg/dl. CA125 (49). BHCG (1) ml∙u/ml.
A decision was made to perform surgery, during the surgery several hard blocks were seen in the abdomen with free movement, white color and different morphologies in different sizes ranging from 5 mm to 4 cm. In the pelvis, uterus was slightly enlarged with a cluster shaped mass palpated on the both sides of the rectum (Figures 3-7).
Figure 1. Ultrasound shows calcification lesions at the side of the uterus.
Figure 2. CT scans show multiple calcifications in the abdomen and pelvis.
Figure 3. Macroscopic lesions extracted from the abdomen with uterus.
Figure 4. Macroscopic lesions extracted from the abdomen with uterus.
Figure 5. Lesions located behind the peritoneum on the anterior wall of the rectum.
Figure 6. Macroscopic lesions extracted from the abdomen with uterus.
Figure 7. Lesions located behind the peritoneum on the anterior wall of the rectum.
2. Total Abdominal Hysterectomy and Bilateral Oophorectomy
General surgery physicians were called, they dissected around the rectum and partial resection of the cluster-shaped retroperitoneal mass was performed, as it was observed that there is extension on both sides of the spine, which made it difficult to remove totally. Pathological report (simple and complex endometrial hyperplasia with focal mild atypia chronic cystic endocervitis, serous cystadenofibroma 15 mm left aovary collagenized fibrous nodules with secondary calcification. Omentum: free of disease and contains one benign lymph node.
In pathology these blocks was diagnosed as collagenase fibrous nodules with secondary calcification. It was observed also simple and complex endometrial hyperplasia with focal atypical.
Calcifying fibrous tumor (CFT) is a benign lesion characterized by its specific histological findings and is found as solitary or multiple lesions in several locations of the human body .
This tumor was first described in the deep soft tissue in children by Rosenthal and Abdul-Karim , but subsequent reports revealed the occurrence of this lesion also in adults. Common sites that CFT arises from are pleura, abdominal cavity, mediastinum, heart, lung, neck, mandible, oral, inguinal, paratesticular, intrascrotal, spine, back, arm, and thigh. The etiology and pathogenesis of the tumor are controversial  .
Calcifying fibrous tumor seems to have a female predilection (ratio 1:1.27).
Age distribution seems to be trimodal with first pick at 0 to 4 years, a second one in the mid-20 s, and a third one in the mid-30 s.
This trimodal distribution may reflect different pathogenesis in the 3 different groups.
Concerning the third spike (around thirties), there are many indications that CFT results as a late sclerosing stage of myofibroblastic tumor  . Malignancy was denied in our patient by pathological examination.
The frequency of the abdominal CFT was estimated to be 1 case per year worldwide based on histopathological archives, but a frequency for CFT as a whole does not exist yet .
Most lesions are generally solitary, but multiple CFTs are also described in the literature   .
Intrabdominal CFTs present with a great variety of symptoms, both general and more specific.
Lack of appetite, fever, weight loss, fatigue, and progressive weakness are examples of general symptoms     .
More specific ones are dyspepsia, flatulence, halitosis, nausea, vomiting, red blood per rectum, and altered bowel habits. The predominant symptom of intrabdominal CFT is chronic pain.
It is characterized as dull, intermittent, progressive, acute, sharp, cramp or not, episodic, local, radiating or not, not-related with the intake of food or epigastric pain after eating with early satiety. Calcifying fibrous tumor (CFT) is a rarely seen entity that usually occurs in children and young adults, with a slight increase in risk in women. Clinically, it appears as a slow growing, no tender mass. Visceral symptoms may occur depending on the localization of the lesions. Radio graphically, it is non-calcified and well circumscribed. Punctate, thick or band-like calcifications can be seen on Computed Tomography (CT). On (MRI), the tumor may be similar to fibromatoses  theiretiology has not been fully clarified yet.
However, in the literature, there are cases that may be related to trauma and Castleman’s disease  . There are no symptoms of systemic disease.
In this case, there was no history of trauma, and the patient was otherwise healthy.
The histo pathological features of CFTs are generally easily recognizable from other reactive or benign neoplastic lesion . However, malignancy was denied in this patient by pathological examination.
The presence of these lesions Peritoneal and Retroperitoneal may suggest other theories for the development of these lesions. The patient was followed up for one year after the surgery by abdominal and pelvic ultrasound, and no new lesions were detected.
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