Sign In
Individual Sign In
Create an Account
Institutional Sign In
OpenAthens Shibboleth
Special Feature
Dec 2011

Image of the Month—Quiz Case

Author Affiliations


Author Affiliations: Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.

Arch Surg. 2011;146(12):1447. doi:10.1001/archsurg.146.12.1447

A 56-year-old African American man with no significant medical history was admitted to the hospital for evaluation of chest pain. During his workup, computed tomography of the chest, abdomen, and pelvis was performed, revealing a well-circumscribed, 3.2 × 3.1-cm mass located in the left pelvis, pressing on the urinary bladder (Figure 1). This mass appeared to contain a central focus of calcification and was not associated with any surrounding enlarged lymph nodes or inflammatory changes. No other abnormal findings were found on computed tomography, and his laboratory values were all within normal limits, including cardiac enzymes. The patient denied any history of abdominal pain, change in bowel habits, weight loss, melena, or urinary symptoms. His abdominal examination did not reveal any tenderness or guarding, and there was no palpable abdominal mass. Finally, a thorough diagnostic evaluation of the chest pain, which spontaneously resolved, failed to reveal any evidence of cardiopulmonary disease.

Image not available

Figure 1. Abdominal computed tomogram demonstrating a well-circumscribed mass (arrow) in the pelvis that abuts the urinary bladder.

The patient was referred to the surgical team for management of this incidental pelvic mass. After discussion with his physician, the patient was scheduled for an elective procedure and was taken to the operating room, where a laparoscopic exploration was performed. On exploration of the intra-abdominal cavity, a free-floating, white, 3.5-cm, ovoid mass was found sitting within the rectovesical pouch (Figure 2A). It was completely nonadherent to any structures and freely rolled around. With the use of laparoscopic graspers, the mass was mobilized from the pelvis and secured in a specimen bag before removal from the abdominal cavity. On gross examination, the mass was smooth and firm and had approximately the size and appearance of a hard-boiled egg (Figure 2B).

Image not available

Figure 2. Free-floating, ovoid mass. Mass was encountered during diagnostic laparoscopy (A) and after removal from the abdominal cavity (B).

What Is the Diagnosis?

A.  Gastrointestinal stromal tumor

B.  Fibrous mesenteric cyst

C.  Encapsulated fat necrosis

D.  Lymphangioma