Download - Retroperitoneal mass
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DR. MD. SHALEH MAHMUDRESIDENT,UROLOGYPHASE- A, Y- 2BSMMU
RETROPERITONEAL MASS : ETIOLOGY & EVALUATION
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Retroperitoneal anatomy Etiology Clinical features Investigations Common retroperitoneal masses
CONTENTS
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RETROPERITONEAL ANATOMY
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Retroperitoneum Boundary
Anteriorly : posterior parietal peritoneum
Posteriorly : Vetebral column, iliopsoas , quadratus lumborum muscle and tendinous part of transverse abdominis
Superiorly : Diaphragm
Inferiorly : Levator Ani and Pelvic Diaphragm
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It is divided into three spaces by the perirenal fascia i.e. fascia of Gerota
The Three spaces are:
Anterior pararenal space Colon, Pancreas, Duodenum
Perirenal space Kidneys, Adrenal glands, Upper portion of ureters
Posterior pararenal space Fat , connective tissue, nerves
SPACES & CONTENTS
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CAUSES OF RETROPERITONEAL SWELLING
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Solid Neoplastic Retroperitoneal mass
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Solid tumor from other sites: Lymphoma Metastatic germ cell
tumor Renal & Adrenal
Neoplasm Pancreatic Neoplasm Colonic Neoplasm
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Cystic Neoplastic Retroperitoneal mass
Neurilemoma
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Non- Neoplastic Retroperitoneal mass
Solid Cystic Retroperitoneal fibrosis ( ORMOND’S Disease)
Hematoma
Urinoma
Psoas Abscess
Pseudocyst
Others : Abdominal aorta aneurysm
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CLINICAL PRESENTATION
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Presentation Asymptomatic: diagnosis is
accidental or Incidental.
most common presentation is huge abdominal lump with compressive symptoms
presentation is usually late : because
i) tumors are slow growing & painless: pain occurs in benign pathologies like Hemangioma, Schwannoma, fibroma, hematoma etc.
ii) tumors displaces the adjacent structures. Infiltration occurs in late stages.
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Due to retroperitoneal mass :1) No clinical findings unless the swelling is very large on
examination:
Consistency : Firm to hard mass , surface : Usually Smooth , but in lymphoma it is nodular , Margins : Ill defined because of deep position , Movement : Not moving with respiration , Mobility : Non mobile, Tenderness : Usually non tender, Pulsatility : sometime pulsatile, Does not fall forward (confirmed by knee-elbow position).
2) Dull aching abdominal pain or Flank pain if RCC
SYMPTOMS AND SIGNS OF RETROPERITONEAL MASS
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Due to compression on adjacent organs :
i) Back Pain - Severe back pain by tumor mass, hematoma and abscess over muscles, facet joint and vertebral column.
Radicular Pain - Radiating type of pain along the nerve root due to its compression.
ii) Obstruction of Viscera and Tubular Organs – usually of duodenum , colon , ureter , pancreas, kidney etc.
Nausea and Vomiting Colicky Pain Constipation/ intestinal obstruction Urinary Retention / Hydroureteronephrosis / Obstructive Uropathy.
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iii) Compression of Aorta
Hypertension Renal Insufficiency Mesenteric Ischemia Intermittent Claudication
iv) Compression of Vena Cava
Edema of Feet Low Blood Pressure
v) Nerve Lesions
Tingling and Numbness in Lower limbs Weakness of the Lower limbs
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Constitutional symptoms: Fatigue Weakness Fever Loss of Appetite Loss of weight Back Pain
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INVESTIGATIONS FOR RETROPERITONEAL MASS
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INVESTIGATION
1) Routine blood investigations: to know about i) CBC : Anemia, Leukocytosis ii) Serum Creatinine : Obstructive Uropathy iii) Liver function test iv) Effect of paraneoplastic syndrome
RBS- HypoglycemiaS. Calcium- Hypercalcemia Blood /Urinary- Catecholamines
v) Tumor markers :- AFP, Beta-HCG, LDH
2) Chest X ray PA view:- Lung metastasis
3) Plane X ray abdomen:- signs of intestinal obstruction, obliterated psoas shadow, calcification of tumor mass.
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4) USG abdomen : nature of mass(solid/cystic) and relation to the adjacent structures.
5) CT / MRI abdomen and pelvis Site, size , relationship to adjacent organs , planning for operation , metastases can be determined.
Contrast enhanced CT has got better tissue delineation
6) PET-CT No defined role in primary level FDG uptake does correlate with
tumor grade in soft tissue sarcoma. Detect metastatic disease.
7) Chest CT
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8) ARTERIOGRAPHYFINDING SUGGESTIVE OF NEOPLASIA INCLUDES :
Neovascularization
Tumor blush
Vessel Encasement
Demonstration of extra-renal artery helpful in kidney sparing surgery.
A DOMINANT LUMBER OR INTERCOSTAL ARTERIAL SUPPLY ADDS TO THE LIKELIHOOD THAT THE TUMOR HAS A RETROPERITONEAL ORIGIN.
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9) CT/USG guided/Laparoscopic core biopsy :Indications of preoperative biopsy An unusual appearing mass non-resectable tumor Distant metastasis Patient being considered for
neoadjuvant chemotherapy
10) FNAC : has got limited role.
11) IVU ;- obstruction and displacement of kidney and ureter, distortion of renal pelvis and bladder compression.
12) Confirmation of diagnosis is only by tissue biopsy.
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Retroperitoneal Sarcoma Rare tumors , only 1–2 % of all solid
malignancies (10–20 % of all sarcomas are retroperitoneal )
The peak incidence is in the fifth decade of life
Common Types :• liposarcoma - 33%• leiomyosarcoma;• malignant fibrous histiocytoma (MFH).
Present late, because arise in the large potential spaces of the retroperitoneum and can grow very large without producing symptoms.
Nonspecific symptoms - abdominal fullness, dull aching pain.
The overall prognosis is worse than that with extremity sarcomas
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1) LIPOSARCOMA:well differentiated liposarcoma showing huge heterogeneous mass with predominantly fat attenuation.
2) LIPOMA: T1 weighted MRI. Homogenous high signal intensity mass.
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Most common retroperitoneal malignancy, about 33%
age group : 40–70-yearfrequently manifests with
extra-nodal disease in the liver, spleen, or bowel, often at an advanced stage.
History of fever , myalgia , night sweats , weight loss
Para aortic lymph nodes involved in 25% with Hodgkin lymphoma and 55% with non-Hodgkin lymphoma.
LYMPHOMA
NHL
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Germ cell tumor < 10% of Teratomas are found in the
retroperitoneum. Third most common tumor in the
retroperitoneum in children, after neuroblastoma and Wilm’s tumor
Females > Male, bimodal age distribution (<6 months and early adulthood).
Mature Teratoma (Dermoid cyst)
contains well-differentiated tissues from at least two germ cell layers.
Mature teratomas are predominantly cystic.
Calcification (tooth like or well defined) and fat can be seen in 56% and 93% of cases, respectively
TERATOMA
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Caused by trauma , blood dyscrasia , anticoagulation therapy , rupture of an abdominal aortic aneurysm , or interventional or surgical procedures .
Occasionally, the heterogeneous appearance on CE-CT images can be confused with a sarcoma
the well-defined margin, the absence of contrast enhancement, the changing appearance with t ime, a progressive decrease in size,
…..dist inguish retroperitoneal hematoma from sarcoma
low signal intensity on MR images because of hemosiderin deposit ion.
RETROPERITONEAL HEMATOMA
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A collection of extravasated urine that is found secondary to trauma or iatrogenic causes.
A well-defined cystic lesion is seen in the retroperitoneum, more commonly in the peri-renal space.
CT shows a well-defined fluid
collection with progressively increasing attenuation caused by contrast-enhanced urine entering the urinoma
URINOMA
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A fibro-inflammatory mass envelops and potentially obstructs retroperitoneal structures.
Fibrous, whitish plaque encases aorta, IVC & their major branches, ureters, other retroperitoneal structures,may involve GIT.
Idiopathic-70%(Ormond’s disease) Definitive etiology in 30%.
Symptoms - dull, poorly localized, non colicky pain in flank, back, or lower abdomen. Unrelated to posture
MRI can distinguish from other pathology
RETROPERITONEAL FIBROSIS
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