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RETROPERITONEAL MASS : ETIOLOGY & EVALUATION
DR. MD. SHALEH MAHMUDRESIDENT,UROLOGYPHASE- A, Y- 2BSMMU
RETROPERITONEAL MASS : ETIOLOGY & EVALUATION
Retroperitoneal anatomy Etiology Clinical features Investigations Common retroperitoneal massesCONTENTS
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
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
Causes of Retroperitoneal Swelling
Solid Neoplastic Retroperitoneal mass
Solid tumor from other sites:
LymphomaMetastatic germ cell tumor Renal & Adrenal NeoplasmPancreatic NeoplasmColonic Neoplasm
Cystic Neoplastic Retroperitoneal mass
Non- Neoplastic Retroperitoneal mass Solid Cystic Retroperitoneal fibrosis ( ORMONDS Disease)Hematoma UrinomaPsoas AbscessPseudocyst
Others : Abdominal aorta aneurysm
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.
Due to retroperitoneal mass :
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
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.
Obstruction of Viscera and Tubular Organs usually of duodenum , colon , ureter , pancreas, kidney etc.
Nausea and VomitingColicky PainConstipation/ intestinal obstructionUrinary Retention / Hydroureteronephrosis / Obstructive Uropathy.
iii) Compression of Aorta
HypertensionRenal InsufficiencyMesenteric IschemiaIntermittent Claudication
iv) Compression of Vena Cava
Edema of FeetLow Blood Pressure
v) Nerve Lesions
Tingling and Numbness in Lower limbsWeakness of the Lower limbs
FatigueWeaknessFeverLoss of AppetiteLoss of weightBack Pain
Investigations FOR retroperitoneal mass
Investigation 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.
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-CTNo defined role in primary levelFDG uptake does correlate with tumor grade in soft tissue sarcoma.Detect metastatic disease.
7) Chest CT
FINDING SUGGESTIVE OF NEOPLASIA INCLUDES :
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.
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.
Retroperitoneal SarcomaRare tumors , only 12 % of all solid malignancies (1020 % 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
1) LIPOSARCOMA:well differentiated liposarcoma showing huge heterogeneous mass with predominantly fat attenuation.
2) LIPOMA: T1 weighted MRI. Homogenous high signal intensity mass.
Most common retroperitoneal malignancy, about 33% age group : 4070-yearfrequently manifests with extra-nodal disease in the liver, spleen, or bowel, often at an advanced stage. History of fever , myalgia , night sweats , weight lossPara aortic lymph nodes involved in 25% with Hodgkin lymphoma and 55% with non-Hodgkin lymphoma. LYMPHOMA
Germ cell tumor< 10% of Teratomas are found in the retroperitoneum.Third most common tumor in the retroperitoneum in children, after neuroblastoma and Wilms tumor Females > Male, bimodal age distribution (