Retroperitoneal mass : etiology & evaluation

2. DR. MD. SHALEH MAHMUD
RESIDENT,UROLOGY
PHASE- A, Y- 2
BSMMU
RETROPERITONEAL MASS :
ETIOLOGY & EVALUATION

3. Retroperitoneal anatomy
 Etiology
 Clinical features
Investigations
Common retroperitoneal masses
CONTENTS

4. RETROPERITONEAL ANATOMY

5. 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

6. 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

9. CAUSES OF RETROPERITONEAL
SWELLING

10. Solid Neoplastic Retroperitoneal mass

11. Solid tumor from other
sites:
 Lymphoma
 Metastatic germ cell tumor
 Renal & Adrenal Neoplasm
 Pancreatic Neoplasm
 Colonic Neoplasm

12. Cystic Neoplastic Retroperitoneal mass
Neurilemoma

13. Non- Neoplastic Retroperitoneal mass
Solid Cystic
Retroperitoneal fibrosis
( ORMOND’S Disease)
Hematoma
Urinoma
Psoas Abscess
Pseudocyst
Others : Abdominal aorta aneurysm

14. CLINICAL PRESENTATION

15. 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.

16.  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

17.  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.

18. 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

19.  Constitutional symptoms:
 Fatigue
 Weakness
 Fever
 Loss of Appetite
 Loss of weight
 Back Pain

20. INVESTIGATIONS FOR
RETROPERITONEAL MASS

21. 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- Hypoglycemia
S. 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.

22. 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

23. 8) ARTERIOGRAPHY
FINDING 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.

24. 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.

25. 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

26. 1) LIPOSARCOMA:
well differentiated liposarcoma
showing huge heterogeneous mass
with predominantly fat attenuation.
2) LIPOMA: T1 weighted MRI.
Homogenous high signal intensity
mass.

27.  Most common retroperitoneal
malignancy, about 33%
 age group : 40–70-year
 frequently 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

28.  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

29.  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 time,
 a progressive decrease in size,
…..distinguish retroperitoneal hematoma
from sarcoma
 low signal intensity on MR images because
of hemosiderin deposition.
RETROPERITONEAL HEMATOMA

30.  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

31.  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