In this case report, we present two important clinical implications. First, preoperative angiography followed by TAE enables safe and complete resection of SFTs occupying the narrow pelvic cavity, although careful management to avoid complications related to intestinal ischemia is needed. Second, embolization of the tumor-feeding artery may be an effective option in addition to medical and surgical treatment for persistent hypoglycemia due to Doege–Potter syndrome.
Although surgical resection is the definitive treatment in most cases of SFTs, large-sized tumors with a hypervascular nature that occupy the pelvic cavity frequently make surgical removal technically difficult . Previous reports have revealed that surgical resection of SFTs occupying the pelvic cavity can be dangerous, associated with a large amount of intraoperative hemorrhage up to 13,660 mL [4,5,6], and may even result in intraoperative death due to uncontrollable hemorrhage . Moreover, such giant tumors make it difficult for surgeons to presume their feeding arteries from preoperative imaging because of the displacement and compression of the adjacent organs by the tumor. In this context, precise preoperative identification of tumor-feeding vessels using angiography followed by TAE is a prerequisite for achieving complete resection without unexpected intraoperative hemorrhage for such giant pelvic SFTs. In our case, CT and MRI showed apparent signs of the inferior mesenteric artery as the main feeding artery of the SFT, and the involvement of the iliac artery was not suspected. However, angiography showed that the tumor was also supplied by the bilateral internal iliac artery, which led to a precise understanding of the hemodynamics of the tumor, along with safe and complete resection after TAE. Surgeons should consider preoperative angiography and TAE when planning resection of hypervascular tumors, such as SFTs, especially large tumors in the pelvic cavity, in order to achieve satisfactory results.
When performing TAE for SFTs, we should be aware of complications related to ischemia. Some authors have described the use of preoperative TAE with no complications in abdominopelvic SFTs irrigated by the iliac artery [7, 8]. In our patient, the tumor was also supplied from the bilateral iliac artery, but the dominant vascularity was the inferior mesenteric artery. Since we were concerned about intestinal ischemia after embolization, we scheduled TAE 2 days prior to the surgery. Despite performing super-selective arterial embolization of the tumor with meticulous attention not to embolize the rectum and the sigmoid colon, the patient suffered from abdominal pain and fever, and operative findings revealed partial necrosis of the rectum. There are no guidelines that reveal when to perform preoperative TAE to reduce the amount of intraoperative hemorrhage. Considering the potential of intestinal ischemia, especially for tumors in which the inferior mesenteric artery is the main feeder, it is reasonable to perform such TAE within 1 or 2 days before surgery, and the patient should be carefully observed after TAE to avoid overlooking the symptoms of ischemic complications.
NICTH is most commonly described with tumors of mesenchymal or hepatic origin. Of the 288 NICTH cases reviewed, 22% were SFTs that were commonly located in the pleura, retroperitoneum, abdomen, and pelvis . Initial management of hypoglycemia in NICTH involves increased caloric intake and frequent intravenous administration of glucose or dextrose. Total resection of the tumor is curative for hypoglycemia in many cases. For cases of uncontrollable hypoglycemia or unresectable tumors, glucocorticoid administration and local antitumor therapy, such as systemic chemotherapy , molecular targeted therapy , and radiation therapy  have been reported to be successful in resolving hypoglycemia. TAE for tumors was effective in treating NICTH in a hepatic fibrosarcoma case  but not in four cases of SFT . To the best of our knowledge, this is the first case that showed TAE for a tumor to be an effective method for controlling hypoglycemia in Doege–Potter syndrome. For Doege–Potter syndrome with refractory hypoglycemia or inoperable tumors, TAE may be an option for resolving hypoglycemia.