retroperitoneal/abdominal masses overview - ucsf · pdf fileretroperitoneal/abdominal masses...

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Retroperitoneal/Abdominal MassesRetroperitoneal/Abdominal Masses
Eric NakakuraEric NakakuraUCSF Department of SurgeryUCSF Department of SurgeryDivision of Surgical OncologyDivision of Surgical Oncology
UCSF Hellen Diller Family Comprehensive Cancer CenterUCSF Hellen Diller Family Comprehensive Cancer Center
UCSF Postgraduate Course in General SurgeryUCSF Postgraduate Course in General SurgeryStanford Court HotelStanford Court HotelSan Francisco, CASan Francisco, CA
April 30, 2010April 30, 2010
Retroperitoneal/Abdominal MassesRetroperitoneal/Abdominal MassesOverviewOverview
Case presentation
Differential diagnosis
Preoperative considerations: work-up and planning
Radiation therapy
Advanced disease
UCSF experience
Retroperitoneal MassRetroperitoneal MassCase presentationCase presentation
53-year-old woman
April 2007: right LE pain
MRI: herniated disc; steroid injections
Dec. 2007: abdominal pain; CT: retroperitoneal mass

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53-year-old woman
Dec. 2007: CT-guided core needle biopsy
Spindle cell neoplasm:
No mitotic figures, no necrosis, SMA +, desmin +
Smooth muscle neoplasm, uncertain malignant potential
Deemed unresectable elsewhere
Adriamycin, ifosfamide, mesna for 2 cycles
March 2008: UCSF for second opinion
Initial impression at UCSF
Leiomyosarcoma arising from the IVC
Appears to be low-grade
Only chance for cure is surgical resection
Wide margins not feasible
May need right nephrectomy
Appears to be anterior and away from right femoral nerve
53-year-old woman
Preoperative consultation with vascular surgeon (C.E.)
Preoperative consultation with radiation oncology (A.G.)
Right ureteral stent placed by urology (K.G.)
Resection of RP neoplasm with en-bloc infrarenal IVC

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Right ureterAorta
PTFE bypass graft
IORTLead protection ofright kidney and ureter15 Gy via 9 cm cone
53-year-old woman
Pathology: 11.5 cm, leiomyosarcoma, grade I, margins negative
Adjuvant external beam radiation therapy
2 years postoperative: no evidence of disease
PTFE bypass graft

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Retroperitoneal MassRetroperitoneal MassPreoperative considerationsPreoperative considerations
Contiguous organ removal
Kidney, colon, pancreas, IVC, iliac vessels, nerve root
Proximity to ureter
Proximity to femoral nerve
Anticipated close surgical margins
Preoperative alpha-blockade (functioning paraganglioma)
Preoperative angioembolization
Retroperitoneal MassRetroperitoneal MassDifferential diagnosisDifferential diagnosis
malignantsarcomaGISTlymphomagerm cell tumor
benign lesionslipomaperipheral nerve sheath tumorteratomaparaganglioma
desmoidbenign lesions
lipomaperipheral nerve sheath tumorteratomaparaganglioma

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43-year-old man with abdominal pain for 6 months
43-year-old man with abdominal pain for 6 monthss/p resection RP neoplasm, en-bloc ileocecectomy, right nephrectomypathology: 8.5 cm fibromatosis (desmoid tumor)
38-year-old man with back, hip, thigh pain for 2 years
38-year-old man with back, hip, thigh pain for 2 yearss/p resection RP neoplasmpathology: 8.1 cm benign peripheral nerve sheath tumor (schwannoma)

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44-year-old man with HTN (4 anti-hypertensive medications) and abdominal pain.
Multifocal functional paraganglioma of the retroperitoneum and bladder
Preoperative embolization of a functional paraganglioma of the retroperitoneum
30-year-old man with enlarging right abdominal mass for 1 year

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30-year-old man with enlarging right abdominal mass for 1 years/p resection RP neoplasm with en-bloc IVC PTFE tube graftpathology: 18 cm leiomyosarcoma (grade 1), arising from IVC
IVC
What is the preferred imaging modality to evaluate a retroperitoneal mass?
Retroperitoneal MassRetroperitoneal MassImagingImaging
Bastiaannet et al. Cancer Treat Rev 2004.Schwarzbach et al. Ann Surg 2005.
CT: retroperitoneal/intra-abdominal
MRI: suspect nerve root involvement
18FDG-PET: ???
When might a PET scan be useful for the evaluation of patientswith cancer?
clinical uses evolving:1) diagnosis (evaluate solitary pulmonary nodules)2) staging (recurrent disease, nodal disease for
epithelioid or angiosarcomas)3) prognostic assessment4) monitoring response to therapy
Podoloff et al. J Natl Compr Canc Netw 2007.

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64-year-old woman 15 months prior underwent resection of RP sarcoma,
left nephrectomy, splenectomy, colectomy pathology: 34 cm well-differentiated liposarcoma surveillance CT: recurrent RP mass
PET/CT revealed: numerous hypermetabolic masses
64-year-old woman s/p re-resection of recurrent RP liposarcoma, IORT pathology: dedifferentiated liposarcoma adjuvant EBRT NED > 4 years postoperatively
Retroperitoneal MassRetroperitoneal MassRole of biopsy?Role of biopsy?
46-year-old woman who developed abdominal pain after a fall

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46-year-old woman who developed abdominal pain after a fallThe next step in her management should be:
A) CT-guided biopsyB) measure plasma-free metanephrines then biopsyC) measure plasma-free metanephrines and surgical evaluation
46-year-old woman who developed abdominal pain after a falls/p resection RP neoplasm, en-bloc right adrenalectomypathology: 10.1 cm paraganglioma (extra-adrenal pheochromocytoma)
Soft Tissue SarcomaSoft Tissue SarcomaBiopsyBiopsy
Heslin et al. Ann Surg Oncol 1997.Hoeber et al. Ann Surg Oncol 2001.
None: resectable retroperitoneal/intra-abdominal
If it will change management:
Fine-needle aspiration: recurrent or metastatic disease
Core-needle biopsy: equivalent to incisional biopsy
Incisional biopsy: less common
Experienced pathologist
Retroperitoneal SarcomaRetroperitoneal SarcomaTreatmentTreatment
Challenges
Large size
Proximity to/invasion of adjacent structures
bowel, vessels, nerves, bones, kidney, ureter, bladder
Complete resection difficult
High local recurrence rate/poor survival

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Soft Tissue SarcomaSoft Tissue SarcomaSurgerySurgery
Rosenberg et al. Ann Surg 1982.NCCN 2005.
Principals of surgeryOptimal margins and oncologic controlMaximal function and minimal morbidityLimb sparing generally preferable
Consider preoperative cytotoxic therapy (chemotherapy, RT),if unable to achieve the above.
Retroperitoneal NeoplasmRetroperitoneal NeoplasmIntraoperative neurophysiological monitoringIntraoperative neurophysiological monitoring
Guo et al. Ann Surg Oncol. (2008).
Soft Tissue SarcomaSoft Tissue SarcomaPrimary retroperitonealPrimary retroperitoneal
classification systemclassification system
Low grade High grade 5-year survival (%)
Complete resection
Incomplete resection
Distant metastasis
I 70-90
II 40-45
III 25
IV 0-15
I II
III
IV
van Dalen et al. Ann Surg Oncol. 2004.
Retroperitoneal SarcomaRetroperitoneal SarcomaOutcomeOutcome
1Ann Surg. 1998.2Cancer. 2001.3Eur J Surg Oncol. 2001.4Cancer. 2004.5Ann Surg. 2004.6J Surg Oncol. 2005.7Ann Surg Oncol. 2006.
5-year
complete resection local recurrence metastasis survival
Lewis et al. (MSKCC)1 67%

retroperitoneal/abdominal masses overview - ucsf · pdf fileretroperitoneal/abdominal masses...

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