C A S E / Uterine adenocarcinoma following incomplete ovariohysterectomy

were strong, but almost of a water-hammer type, suggesting above-normal pressure of contraction. The respiratory rate was within normal limits. Given the history, and previous identification of extensive intra-abdominal cystic lesions, exploratory abdominal surgery was recommended as ultrasound-guided aspiration or biopsy was considered unlikely to yield a diagnostic sample. Pre-anesthetic tests indicated a moderate anaemia (packed cell volume 20%, reference interval [RI] 3045%). Electrolytes, urea (9.0 mmol/l, RI 5.712.9), creatinine (95 mmol/l, RI 71212) and clotting times were within normal limits. Blood lactate was 1.3 mmol/l (normal <2.5 mmol/l). Exploratory coeliotomy On exploratory coeliotomy, performed via a standard xiphoidpelvic brim incision, a large multilobed cystic mass was identified occupying almost the entire abdominal cavity (Fig 1). The bladder was sitting immediately caudoventral to the mass, together with a distended uterine body containing purulent material. The vena cava was displaced to the left side of the abdomen, had become incorporated within the wall of the cystic mass, and was tortuously kinked due to multiple points of adhesion. The right kidney was also to the left of midline, and was adhesed to the cranial aspect of the cystic mass. The proximal right ureter was visualised running into the mass, and terminating within it. The distal right ureter was identified leaving the mass and was followed to the trigone to confirm its provenance. The mass contained approximately 1 litre of fluid, which biochemical analysis subsequently confirmed to have urea (9.3 mmol/l) and creatinine (101 mol/l) levels higher than the serum levels. This is consistent with extravasated urine that has been contained and partially resorbed. The left ureter was identified and traced intact from the trigone to the left kidney. The mass was carefully and progressively dissected free of the vena cava, left kidney and renal vessels, and left ureter. Multiple adhesions between the body wall and the mass were transected. At this point a thin tubular structure, approximately 22.5 mm in diameter, was identified running within the left side of the cystic mass, which further evaluation confirmed to be the abdominal aorta (Fig 2). The aortic constriction extended from adjacent to the diaphragm to the caudal abdomen, where the vessel terminated in a hard mass of fibrous tissue immediately beside the uterine body. The vena cava also joined this fibrous area, and here a ballooning of the vessel walls could be seen.

FIG 1 Drainage of the cystic mass confirmed that it was a urinoma

FIG 2 Fibrous remnant of the abdominal aorta, approximately 2 mm in diameter

Unfortunately, at this point in the surgery the cat suffered a full cardiorespiratory arrest and resuscitation was unsuccessful.
FIG 3 Histopathology of uterine adenocarcinoma. The single arrow indicates the papillary projections into the lumen, and the double arrow identifies the necrotic debris within the lumen. (inset) The dilated endometrial glands lined with tumour cells

Histopathology Histopathology of the uterus (Fig 3) identified a thickened endometrium with papillary projections into the lumen, and irregularly shaped dilated endometrial glands lined with layers of tumour cells. There was extensive necrosis of tumour cells with many glandular

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C A S E / Uterine adenocarcinoma following incomplete ovariohysterectomy

Recurrent oestrous cycles are the most common clinical sign of ovarian remnant syndrome; albeit there may be an interval of years between ovariohysterectomy and signs of oestrus.
spaces and the uterine lumen contained necrotic debris. The tumour cells were columnar with a moderate amount of eosinophilic cytoplasm, a hyperchromatic ovoid and central nucleus, and a prominent, central, deeply eosinophilic nucleolus. There was a moderate degree of anisokaryosis, a large number of multinucleate cells, and one to three mitotic figures per high power field. Neoplastic cells were also identified in the aorta, perirenal tissue and cystic structure. The cells seen within these structures differed from the tumour cells within the uterus as they were polygonal, rather than cuboidal, had more variance in both the shape of the nuclei and number of nucleoli, and demonstrated marked (as opposed to moderate) anisokaryosis and a higher mitotic index (up to eight mitotic figures per high power field). The shared characteristics included the eosinophilic cytoplasm and deeply eosinophilic nucleoli. These histopathological features are consistent with metastatic spread of the tumour from a primary glandular tumour most likely from the endometrium of the uterine stump. categories anatomical variation and surgical error. Anatomical variants include the presence of an accessory ovary or extension of ovarian tissue into the ovarian ligament, which becomes functional after removal of the ovary. Potential surgical errors include improper clamp placement, dropping of ovarian tissue, and a small surgical incision that limits visualisation.12,13 Recurrent oestrous cycles are the most common clinical sign of ORS; albeit there may be an interval of years between ovariohysterectomy and signs of oestrus.11 Diagnosis is based on history, clinical signs, hormonal assays, vaginal cytology and exploratory surgery. This report documents a very unusual complication following an incomplete ovariohysterectomy. It is likely that the initial surgery and the inflammation caused by further surgical attempts, as well as hormonal drive from the remaining ovarian tissue, led to the development of uterine neoplasia. Invasion of the tumour tissue into surrounding structures created further complications, which included the formation of a large cystic structure consistent with a urinoma (ie, an accumulation of extravasated urine within a fibrous sac). Urinomas occur due to persistent urine leakage from a ureter triggering a fibroblastic reaction that acts to contain the urine within the retroperitoneal space. In humans, despite being rare, they have been reported to occur secondarily to trauma (penetrating or blunt) or obstruction (neoplasia and calculi), and following surgery (urogenital, orthopaedic and vascular procedures, and neurosurgery). In the veterinary literature there are only isolated case reports of urinomas, which include three cases in cats following road traffic accidents, 1416 and one in a dog following ligation during ovariohysterectomy.17

Discussion
Uterine neoplasia is rare in the cat, comprising 0.29% of all feline neoplasms in one study.1 Overall, uterine leiomyoma and adenocarcinoma have been the most common tumours described in retrospective studies limited to tumours of the feline reproductive system.1,2 Uterine tumours are more commonly found in entire female cats, between 4 and 16 years of age.1,39 Only one case of uterine adenocarcinoma has been reported in an ovariohysterectomised female cat.1 The clinical signs in cats with uterine tumours vary but can include abdominal distension, weight loss, anorexia, pain, vaginal bleeding and infertility.1,9,10 In this case, the cat was displaying signs of prolonged and recurrent oestrus despite attempted ovariohysterectomy, and had abdominal distension, weight loss and pain. The persistent signs of oestrus could be attributed to ovarian remnant syndrome (ORS), which refers to the presence of functional ovarian tissue in a previously ovariohysterectomised animal.11,12 There is some debate in the literature as to the cause of ORS, with suggested causes falling into two broad

It is likely that, in this cat, the initial surgery and the inflammation caused by further surgical attempts, as well as hormonal drive from the remaining ovarian tissue, led to the development of uterine neoplasia.

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C A S E / Uterine adenocarcinoma following incomplete ovariohysterectomy

To the authors knowledge, there have been no previous reports of urinoma formation secondary to neoplasia in feline patients. The other unusual feature of this case was the aortic metastasis, which had led to progressive aortic constriction.
In the case of this cat it is likely that invasion of the right ureter by the tumour led to a slow leakage of urine out of the ureter, producing a urinoma. To the authors knowledge, there have been no previous reports of urinoma formation secondary to neoplasia in feline patients. Urinomas have many synonyms, including para-ureteral pseudocyst and uriniferous pseudocyst. What is important, however, is that they are differentiated from perinephric pseudocysts, which are fluid-filled sacs surrounding the kidney, usually seen in association with chronic renal failure.16,18 The other unusual feature of this case was the aortic metastasis, which had led to progressive aortic constriction and, based on the appearance at surgery, a significantly reduced blood flow. Aortic metastasis has been documented associated with a variety of tumours in people, including colon carcinoma, malignant germ cell testicular tumour and carcinoid tumours.1921 In the main, invasion is reported to the aortic wall, and can be associated with aneurysmal dilation and occasionally spontaneous rupture. By contrast, constriction or progressive occlusion is only infrequently reported. Abdominal aortic, celiac axis and mesenteric arterial occlusion due to neoplastic thrombosis has been recently reported in an elderly woman, associated with a 2-week history of abdominal pain,21 and it may be that the progressive aortic occlusion in the cat in the present report contributed to the abdominal pain that developed prior to surgery.
adenocarcinoma in a cat. Pathol Vet 1968; 5: 42731. ORourke MD, Geib LW. Endometrial adenocarcinoma in a cat. Cornell Vet 1970; 60: 598604. Gil da Costa RM, Santos M, Amorium I, Lopes C, Dias Piera P, Faustino AM. An immunohistological study of feline endometrial adenocarcinoma. J Comp Pathol 2009; 140: 25459. Sapierzynski RA, Dolka I, Cywinska A. Multiple pathologies of the feline uterus: a case report. Vet Med (Praha) 2009; 52: 34550. Cooper TK, Ronnet BM, Ruben DS, Zink MC. Uterine leiomyosarcoma with widespread metastases in a cat. Vet Pathol 2006; 43: 55256. Wallace MS. The ovarian remnant syndrome in the bitch and queen. Vet Clin North Am Small Anim Pract 1991; 21: 5017. Miller DM. Ovarian remnant syndrome in dogs and cats: 46 cases (19881992). J Vet Diagn Invest 1995; 7: 57274. Ball RL, Birchard SJ, May LR, Threlfall WR, Young GS. Ovarian remnant syndrome in dogs and cats: 21 cases (20002007). J Am Vet Med Assoc 2010; 236: 54853. Bacon NJ, Anderson DM, Baines EA, White RAS. Post-traumatic para-ureteral urinoma (uriniferous pseudocyst) in a cat. Vet Comp Orthop Traumatol 2002; 15: 12326. Moores AP, Bell AMD, Costello M. Urinoma (para-ureteral pseudocyst) as a consequence of trauma in a cat. J Small Anim Pract 2002; 43: 21316. Worth AJ, Tomlin SC. Post-traumatic paraureteral urinoma in a cat. J Small Anim Pract 2004; 45: 413416. Tidwell AS, Ullman SL, Schelling SH. Urinoma (para-ureteral pseudocyst) in a dog. Vet Radiol 1990; 31: 2036. Ochoa VB, DiBartola SP, Chew DJ, Westropp J, Carothers M, Biller D. Perinephric pseudocysts in the cat: a retrospective study and review of the literature. J Vet Intern Med 1999; 13: 4755. Lampl LH. Carcinoid tumor invading the thoracic aorta: en-bloc resection. Thorac Cardiovasc Surg 1991; 39: 3089. Baretti R, Schaumann B, Meyer R, Alfaouri D, Hetzer R. Metastasizing malignant germ cell tumor of the testis with infiltration of the thoracic aorta a case for metastasis surgery. Dtsch Med Wochenschr 2000; 125: 116466. Serck LC, Cogbill TH. Aortic, celiac axis, and superior mesenteric artery thrombosis associated with sigmoid colon adenocarcinoma and hypercoagulable state. Vasc Endovascular Surg 2009; 43: 28485.

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Acknowledgements
The authors wish to thank Janet PattersonKane and Adrian Philbey.

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References
1 Miller MA, Ramos-Vara JA, Dickerson MF, et al. Uterine neoplasia in 13 cats. J Vet Diagn Invest 2003; 15: 51522. Papparella S, Roperto F. Spontaneous uterine tumours in three cats. Vet Pathol 1984; 21: 25758. Meier H. Carcinoma of the uterus in the cat: two cases. Cornell Vet 1956; 46: 188200. Preiser H. Endometrial adenocarcinoma in a cat. Pathol Vet 1964; 1: 48590. Schmidt RE, Langham RF. A survey of feline neoplasms. J Am Vet Med Assoc 1967; 151: 132528. Belter LF, Crawford EM, Bates HR. Endometrial 19

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