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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

    Retroperitoneal MassRetroperitoneal MassCase presentationCase presentation

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    Retroperitoneal MassRetroperitoneal MassCase presentationCase presentation

    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

    Retroperitoneal MassRetroperitoneal MassCase presentationCase presentation

    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

    Retroperitoneal MassRetroperitoneal MassCase presentationCase presentation

    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.)

    Retroperitoneal MassRetroperitoneal MassCase presentationCase presentation

    Resection of RP neoplasm with en-bloc infrarenal IVC

  • 3

    Retroperitoneal MassRetroperitoneal MassCase presentationCase presentation

    Right ureterAorta

    PTFE bypass graft

    Retroperitoneal MassRetroperitoneal MassCase presentationCase presentation

    IORTLead protection ofright kidney and ureter15 Gy via 9 cm cone

    Retroperitoneal MassRetroperitoneal MassCase presentationCase presentation

    53-year-old woman

    Pathology: 11.5 cm, leiomyosarcoma, grade I, margins negative

    Adjuvant external beam radiation therapy

    Retroperitoneal MassRetroperitoneal MassCase presentationCase presentation

    2 years postoperative: no evidence of disease

    PTFE bypass graft

  • 4

    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

    malignantsarcomaGISTlymphomagerm cell tumor

    benign lesionslipomaperipheral nerve sheath tumorteratomaparaganglioma

    Retroperitoneal MassRetroperitoneal MassDifferential diagnosisDifferential diagnosis

    malignantsarcomaGISTlymphomagerm cell tumor

    desmoidbenign lesions

    lipomaperipheral nerve sheath tumorteratomaparaganglioma

    Retroperitoneal MassRetroperitoneal MassDifferential diagnosisDifferential diagnosis

  • 5

    43-year-old man with abdominal pain for 6 months

    Retroperitoneal MassRetroperitoneal MassDifferential diagnosisDifferential diagnosis

    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)

    Retroperitoneal MassRetroperitoneal MassDifferential diagnosisDifferential diagnosis

    38-year-old man with back, hip, thigh pain for 2 years

    Retroperitoneal MassRetroperitoneal MassDifferential diagnosisDifferential diagnosis

    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)

    Retroperitoneal MassRetroperitoneal MassDifferential diagnosisDifferential diagnosis

  • 6

    44-year-old man with HTN (4 anti-hypertensive medications) and abdominal pain.

    Retroperitoneal MassRetroperitoneal MassDifferential diagnosisDifferential diagnosis

    Multifocal functional paraganglioma of the retroperitoneum and bladder

    Retroperitoneal MassRetroperitoneal MassDifferential diagnosisDifferential diagnosis

    Preoperative embolization of a functional paraganglioma of the retroperitoneum

    Retroperitoneal MassRetroperitoneal MassDifferential diagnosisDifferential diagnosis

    30-year-old man with enlarging right abdominal mass for 1 year

    Retroperitoneal MassRetroperitoneal MassDifferential diagnosisDifferential diagnosis

  • 7

    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

    Retroperitoneal MassRetroperitoneal MassDifferential diagnosisDifferential diagnosis

    IVC

    What is the preferred imaging modality to evaluate a retroperitoneal mass?

    Retroperitoneal MassRetroperitoneal MassImagingImaging

    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.

    Retroperitoneal MassRetroperitoneal MassImagingImaging

  • 8

    Retroperitoneal MassRetroperitoneal MassImagingImaging

    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

    Retroperitoneal MassRetroperitoneal MassImagingImaging

    64-year-old woman s/p re-resection of recurrent RP liposarcoma, IORT pathology: dedifferentiated liposarcoma adjuvant EBRT NED > 4 years postoperatively

    Retroperitoneal MassRetroperitoneal MassImagingImaging

    Retroperitoneal MassRetroperitoneal MassRole of biopsy?Role of biopsy?

    46-year-old woman who developed abdominal pain after a fall

  • 9

    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

    Retroperitoneal MassRetroperitoneal MassRole of biopsy?Role of biopsy?

    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)

    Retroperitoneal MassRetroperitoneal MassRole of biopsy?Role of biopsy?

    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

  • 10

    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%

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