Retroperitoneal Location Research Articles

Multidetector computed tomography scan for renal cell carcinoma: A review

Renal cell carcinoma (RCC) is the most common renal malignant tumour. Owing to its retroperitoneal location, RCC remains asymptomatic and non-palpable until advanced disease develops. Most cases are identified during radiological examination for other reasons. The management of RCC depends substantially on the effective use of imaging. This is true in all the stages of the RCC, from initial diagnosis to follow-up. This article sets to review the current knowledge about multidetector computed tomography (MDCT) scan and how it characterises the RCC. A search of PubMed database was made to locate the original and review articles in English that address the MDCT scan or RCC, without limit to publication date. Relevant articles and textbook chapters were reviewed, analysed and summarised. MDCT reveals the renal tumour, its extent, venous involvement, status of loco-regional lymph nodes as well as adrenal and liver extension. It is available and relatively affordable presently in some centres across the subregion. MDCT is an essential tool that has aided not only the early diagnosis of RCC, but also the staging and characterisation of the RCC.

A case report of combined injury to the stomach and duodenum following abdominal gunshot wounds

Duodenal injury is an uncommon finding because of its retroperitoneal location, accounting for about 3%–5% of abdominal trauma, resulting from penetrating injuries (75%); mainly due to gunshot injuries and blunt trauma (25%), and it is associated with a significant mortality (6%–25%) and morbidity (30%–60%). In this article, we describe a case of a 17-year-old male, who presented with abdominal gunshot injury.

The investigation of incidence and radiological findings of gastrointestinal stromal tumor as a rare cause of abdominal mass

Aim: The aim of the present study was to evaluate the investigation of incidence and radiological findings of gastrointestinal stromal tumors (GIST) as a rare cause of abdominal mass, with current literature review. Material and Methods: Between February 2011 and May 2016, a total of 4,443 patients who underwent abdominal multislice computed tomography and magnetic resonance imaging due to the clinical indications for abdominal pain, abdominal swellingmass were analyzed in our hospital. The retrospective cross-sectional study included forty-five patients, who were subsequently diagnosed with GIST histopathologically. Results: GIST was identified in 45 (1%) patients. Of the total 45 patients, 21 (47%) were men and 24 (53%) were female. The mean age was 55 years, ranging from 35 to 73 years. As a result of radiological examinations, the tumor location was stomach in 22 cases (49%), small intestine in 12 cases (27%) and colon in 9 cases (20%). The retroperitoneal localization was also found in 2 cases (4%). The average size of the lesions ranged between 2 and 15 cm. Malignant degeneration and omental metastasis were seen in 11 (24%) and 7 cases (16%) respectively. Conclusion: GIST is a rare cause of abdominal mass with an incidence of 1% in our region. They are most commonly localized in the stomach, rarely in the omentum/mesentery and retroperitoneum. The Malignant transformation is not frequent. Diagnosis and evaluations of mass can be made successfully by radiological imaging modalities.

Unresectable and Metastatic Pancreatic Adenocarcinoma in the Elderly: A 10-Year, Single-Center Experience

Introduction: Pancreatic adenocarcinoma is the fourth leading cause of cancer deaths in Canada and mainly affects individuals older than 60 years of age. It is associated with particularly high 1 and 5-year mortality rates of 75% and 94% respectively. Because of its retroperitoneal location, pancreatic cancer follows a relatively silent clinical course and is more often diagnosed at an advanced stage, thereby ruling out the possibility of surgical resection and cure. When faced with a diagnosis of unresectable pancreatic adenocarcinoma, patients may be offered palliative chemotherapy. Unfortunately, a paucity of data exists regarding the use, efficacy and safety profile of chemotherapeutic agents in the elderly population with pancreatic cancer; this specific population being often excluded from randomized trials. With already 1 in 6 Canadians aged older than 65 years old and an aging population, clinicians are bound to be faced with oncologic decisions regarding treatment of those under-represented elderly patients with pancreatic adenocarcinoma. It is therefore imperative to study this population in order to offer adapted and proven treatment protocols and ensure adequate and optimal care. Methods: This is a retrospective observational study of all patients aged older than 75 years old with a diagnosis of unresectable or metastatic pancreatic cancer at the CHUS between June 2005 and June 2015. Data was retrieved using the local patient database program Ariane. Results: During the study period, 186 patients were included according to the entry criteria. Median age at diagnosis was 82 years old with a slight female gender predominance (52% vs 48%). Location of the primary tumor was in the head of the pancreas in 46% of cases, and evenly distributed between the pancreatic body and tail. Diagnosis was made by the general practitioners or gastroenterologists in 73.4% of cases. High blood pressure, diabetes mellitus and coronary atherosclerosis were the most frequently encountered comorbidities. Other biochemistry parameters at diagnosis suggested a more fragile population; median albumin level of 32 g/L, median creatinine value of 155 μmol/L and minor anemia (median = 11.7 g/dL). Among the 96 patients who were offered chemotherapy, only 10 accepted this palliative treatment. ECOG status was unfortunately far from uniformly documented, although among the 10 patients treated, all had either ECOG 0 or 1 scores. Nine received Gemcitabine as first line whereas one patient was treated with Folfirinox. Seven completed the treatment with the standard regimen dosage for each cycle. Patients received a median of 5 cycles and end of treatment was dictated by severe asthenia complicating treatment. Only 2 patients, non-responders, received second-line agents (5FU/LV) that were subsequently stopped, again for non-response. Conclusion: Results of this unicentric observational retrospective study suggest an overall diminished clinical performance status in elderly patients (>75 years old) diagnosed with unresectable or metastatic pancreatic cancer when compared to their younger counterparts. Due to our small sample size, it remains difficult to draw conclusions on ideal patient selection criterion and palliative treatment for advanced pancreatic cancer in the elderly. The present study does, however, underline the dire need for further studies on the matter.

Diagnosis of Pancreatic Cancer: Can Biopsy Misguide?

Pancreatic cancer remains the second leading cause of cancer related mortality in United States with 48,960 new cases and 40,560 deaths in 2015, with a 5 year survival rate of 7.2%. Due to its retroperitoneal location and insidious course, diagnosis of pancreatic cancer remains elusive. Case Presentation: 76 y/o male with past medical history of hypertension, diabetes and hypothyroidism presented with decreased appetite, 60 pound weight loss, fatigue and pale white stools for a year. Laboratory workup revealed AST and ALT ˜ 200 IU/L, ALP > 1200 IU/L, CEA - 9.9 ng/mL, CA-125 of 81.6 U/mL and CA 19-9 of 12131 U/mL. CT abdomen showed extrahepatic and intrahepatic ductal dilatation, narrowing of common bile duct, soft tissue density in the pancreatic head. (figure 1). EUS revealed a 3x2 cm heterogenous mass in pancreatic head encasing bile duct. FNA of the mass was suggestive of benign cellular elements. Repeat EUS-FNA of the mass was also negative for malignancy. During ERCP, sphincterotomy was performed with multiple biopsies of papilla, which were also negative for malignancy. PET scan was also negative for uptake anywhere (figure 2) Due to multiple co-morbidities he was managed supportively and external biliary drain was placed. Autopsy revealed poorly differentiated pancreatic cystadenocarcinoma with signet ring cells and mucinous infiltration involving pancreatic head and body. (figure 3).Figure 1Figure 2Figure 3Discussion: Algorithm for imaging diagnosis of pancreatic carcinoma includes a multi-detector computed tomography (MDCT), MRCP, or fine-needle aspiration using EUS. MDCT has >96% sensitivity for predicting the resectability of pancreatic cancer, however misses small metastases. EUS produces high resolution images of the pancreas and is useful for tumours < 3 cm. EUS-guided FNA is > 90% sensitive in detecting pancreatic malignancy. In our case despite two EUS- FNA attempts, we were unable to get a tissue diagnosis, which highlights potential fallacies. The necessity of obtaining a cytological or tissue diagnosis of pancreatic cancer prior to surgery remains controversial. However in unresectable cases and where palliation is to be considered, pathological proof of malignancy is required for determining neo-adjuvant chemotherapy. This case highlights the fact that despite many advances we still have long strides to make in techniques for diagnosis of pancreatic cancer, to help institute timely management.

Fetus-in-fetu presenting as a cryptorchid testis and abdominal mass: A report of a case and review of the literature

Abstract Fetus-in-fetu is a rare congenital tumor containing fetal tissue with an unclear etiology, but some believe it to arise from a parasitic monozygotic twin within the host twin. We present the case of a 3-week old term neonate found to have an abdominal mass and undescended right testicle. At laparotomy, a large, circumscribed mass was present in the right upper quadrant. It was found to be associated with the vas deferens and gonadal vessels, appearing to be closely associated with the right-sided cryptorchid testis. Pathology revealed an intratesticular fetus-in-fetu. Fetus-in-fetu is a rare condition where a well-developed mass believed to arise from a monozygotic, parasitic twin, is found within its sibling. First reported by Dr. Meckel in 1800, this is thought to occur in 1 in 500,000 live births with less than 100 cases reported in the literature. Fetus-in-fetu is differentiated from mature teratoma by the presence of an axial skeleton with metameric segmentation and well-differentiated tissues. FIF is a benign disease, however surgical excision continues to be the treatment of choice, in order to confirm diagnosis by pathology and to exclude malignant teratoma. Fetus-in-fetu is a rare of congenital lesion that can present as an abdominal mass. Due to the high prevalence of retroperitoneal location, a FIF should remain on the differential for an infant with an abdominal mass and ipsilateral cryptorchid testis.

RETROPERITONEAL SCHWANNOMA (CLINICAL CASE)

Schwannoma - a tumor growing from Schwann cells of the peripheral nerve sheath. Retroperitoneal schwannoma is a rare tumor accounting for approximately 1 to 5% of all retroperitoneal neoplasms. Retroperitoneal localization occurs for a total in 0.75-2.6% of cases, often they localize in the extremi- ties, the head and neck. Despite the significant progress made currently in the field of instrumental studies for non-organ retroperitoneal tumors, diagnosis and differential diagnosis remain a complex problem requiring further study. Presented clinical case illustrates difficulties in the diagnosis of retro- peritoneal schwannoma. Precise preoperative determination of the tumor relationship with all the nearby organs and vessels according to the different methods of ray diagnostics gives an opportunity to define the tactics of treatment.

Retroperitoneal lymphangioma: A report of 2 cases and a review of the literature regarding the differential diagnoses of retroperitoneal cystic masses.

Cystic lymphangioma is a type of benign tumor originating from the lymph vessels. The tumor commonly occurs in childhood, in the head or neck regions, and retroperitoneal localization and presentations in adulthood are rare. Determining a pre-operative diagnosis is often challenging, and in the majority of cases, a diagnosis is only possible subsequent to the histological examination of the surgical specimen. A radical resection is the recommended treatment for cystic lymphangioma, and recurrence is usually due to an incomplete excision of the mass. The present study reports 2 cases of cystic lymphangioma, localized in the pancreatic gland and duodenal wall respectively, which were treated with surgical resection. The study also briefly reviews the literature regarding the differential diagnosis of retroperitoneal cystic masses.

Localized Castleman’s Disease in Retroperitoneum Mimicking Broad Ligament Leiomyoma – a Diagnostic Challenge

Primary retroperitoneal tumours pose a diagnostic dilemma and therapeutic challenges because of their location and late detection. Localized Castleman Disease (CD) in retroperitoneal location is a rare occurrence, with incidence of only 4% cases occurring in diverse locations like retroperitoneum. A rare case of unicentric localized Castleman Disease localized in broad ligament is hereby reported which was clinically &amp; radiologically suspected as broad ligament leiomyoma but finally diagnosed as Castleman’s Disease, hyaline vascular type in a young female posing a diagnostic challenge both for the pathologist and clinician. Definite diagnosis is essential as complete surgical excision in case of unicentric Castleman’s Disease has good prognosis after resection.

Lymphome de Hodgkin révélé par un syndrome néphrotique : à propos d’un cas

Pediatric nephrotic syndrome (NS) is most often idiopathic or primary but in rare cases, it can be secondary to neoplasia. We report on a case of steroid-resistant NS revealing as a paraneoplastic syndrome of Hodgkin disease (HD) in a 12-year-old boy. The onset of the NS can be earlier, later, or simultaneous to the HD. Treatment of the lymphoma allows the disappearance of the NS. In the case we observed, the diagnosis of HD was delayed because HD presented with an isolated, hilar adenopathy in the absence of retroperitoneal or peripheral locations. In children aged 10 years or more presenting with NS, steroid-resistant or otherwise, a possible paraneoplastic origin such as Hodgkin lymphoma should always be taken into consideration and eventually eliminated.

An unusual retroperitoneal tumour mimicking adrenal pheochromocytoma

ttp://dx.doi.org/10.1016/j.dld.2015.06.009 590-8658/© 2015 Published by Elsevier Ltd on behalf of Editrice Gastroenterologica Ital norepinephrine (964 ng/L). She underwent retroperitoneal tumour resection. Microscopic examination revealed sheets of uniform small, blue, round to oval cells with scant cytoplasm, hyperchromatic chromatin, and inconspicuous nucleoli (Fig. 1B and C). Immunohistochemical analysis showed tumour cells positive for CD99 (Fig. 1D). Fluorescence in situ hybridization further confirmed the diagnosis of Ewing sarcoma/primitive neuroectodermal tumor (ES/PNET). She received a cycle of systemic chemotherapy including pirarubicin, cyclophosphamide and etoposide two weeks after surgery, however she died of multiple metastases 12 months later. ES/PNET is a family of highly malignant tumours composed of small round cells that occurs predominantly in bone and soft tissues of children and young adults. Our case is unique in its rarely retroperitoneal location as previous extranskeletal ES/PNET primarily involved paravertebral locations and the genitourinary tract. Moreover, it mimicked adrenal pheochromocytoma due to the significant rise in plasmatic norepinephrine. Because surgical resection alone often results in rapid recurrence and metastasis, multimodal therapy, combining chemotherapy with local control treatment (surgery and radiation therapy), should be used to improve prognosis [1].

A RARE CASE OF A GIANT RETROPERITONEAL RECURRENT LIPOSARCOMA

We report the case of a giant retroperitoneal liposarcoma, with two rare histological subtypes: pleomorphic subtype at initial surgical resection, and dedifferentiated subtype at the recurrence. A 61-year-old male patient, presented at the University Emergency Hospital Bucharest, for progressive enlargement of the abdomen. The exploratory laparotomy found a deforming mass in the retroperitoneal area, with medial displacement of the left colon, from the splenic flexure to the recto-sigmoid junction. After assessing the resectability of the tumor, it was decided and performed an en-bloc excision of the tumor, without multiorgan resection and with macroscopic free safety margins. Due to the intersection with the genital vessels, their resection was imposed. The tumor was trefoil-shaped, with a diameter of 35 cm. After 7 months of chemotherapy, tumor recurrence occured, within the same location, confirmed as a dedifferentiated subtype. The same surgical procedure was performed, and the oncologist decided to continue with a more aggressive chemotherapy. Pleomorphic liposarcoma has a high rate of recurrence and has a high resistantce at chemotherapy. Due to its deep retroperitoneal location, the relations with the inferior vena cava, the aorta and the genital vessels are essential, in some cases multiorgan resections being necessary.The case presents a rare malignant tumor, a 35 cm diameter retroperitoneal liposarcoma, highly resistant to chemotherapy and with a high recurrence rate.

Robotic-assisted repair of a duodenal diaphragm in a child

Abstract The retroperitoneal location of the duodenum and the small volume of the peritoneal cavity in pediatric patients make the laparoscopic repair of congenital duodenal anomalies challenging. As a result, robotic-assisted repair of duodenal atresia in a pediatric patient has been reported only once in the literature. This report describes the robotic-assisted laparoscopic repair of a congenital duodenal diaphragm in a 2-year-old, 8 kg patient who presented with vomiting and failure to thrive. An upper gastrointestinal series revealed partial obstruction at the second part of the duodenum with proximal dilatation. These findings are consistent with a duodenal diaphragm. Traditional laparoscopy was utilized to kocherize the first and second parts of the duodenum and to identify a loop of proximal jejunum for the proposed anastomosis. A duodeno-jejunal anastomosis was then performed using intra-corporeal suturing with a daVinci SI robotic system. The patient had a quick and uneventful post-operative course. At 6 month follow-up, she was asymptomatic and the surgical incisions had healed with excellent cosmetic appearance. A combination of laparoscopic and robotic techniques offers a promising alternative to open or purely laparoscopic repair of congenital duodenal anomalies.

Penetrating Pancreatic Injury

Pancreatic injury following penetrating trauma is a rare but complex problem in trauma surgery. The retroperitoneal location of the pancreas and its intricate anatomic relationship to other vital structures both contribute to this complexity. Accurate intraoperative diagnosis of pancreatic injury can be difficult, making careful and thorough operative exposure paramount. Operative management is guided by the presence of associated injuries and the severity of the pancreatic injury. External drainage, resection, and staged reconstruction when indicated are the pillars of operative management for the majority of injuries. Post-injury complications are common and can include fistula, pancreatitis, abscess, hemorrhage, and pseudocyst. ERCP is central to the management of these complications and can aid in avoiding return to the operating room. Because of the significant morbidity and mortality associated with penetrating pancreatic injury, collaboration among surgical disciplines is warranted to optimize outcome.

Duodenal Injuries Due to Trauma: Review of the Literature

Duodenal injuries constitute a challenge to the trauma surgeon, mainly due to their retroperitoneal location. When identified, they present associated with other abdominal injuries. Consequently, they have an increased morbidity and mortality. At best estimates, duodenal lesions occur in 4.3% of all patients with abdominal injuries, ranging from 3.7% to 5%, and because of their anatomical proximity to other organs, they are rarely an isolated injury. The aim of this paper is to present a concise description of the anatomy, diagnosis, surgical management and treatment of complications of duodenal trauma, and an analysis of complications and mortality rates of duodenal injuries based on a 46-year review of the literature.

Comparison of Pathological Radicality between Open and Laparoscopic Pancreaticoduodenectomy in a Tertiary Centre.

Laparoscopic pancreaticoduodenectomy (LPD) remained a formidable challenge owing to retroperitoneal location, difficult dissection near great vessels and critical intracorporeal anastomoses. Recent reviews of literature have established the feasibility and comparable short term outcomes of laparoscopic pancreaticoduodenectomy (LPD) with that of open pancreaticoduodenectomy (OPD). This study was undertaken to compare the pathological radicality of LPD with OPD. A prospective database of all patients who underwent standard pancreaticoduodenectomy from Mar 2006 to Feb 2011 was taken up for this study. 45 patients who underwent LPD and 118 patients who underwent OPD for periampullary and pancreatic head malignancy were taken up for analysis. The study groups were comparable in terms of age of presentation, ASA grades, comorbidity, type of surgery and BMI. There was no statistically significant difference with regard to tumor size, lymph node yield, node positivity rates, R1 rates and margin lengths. The pathological radicality of laparoscopic pancreaticoduodenectomy is comparable with that of open approach when performed by experienced minimal-access surgeons. Standardized protocols for evaluation of the resection margins should be mandatory in studies reporting outcomes of pancreaticoduodectomy.

Calcific inflammatory myofibroblastic tumour in the retroperitoneum of a child: a case report

Inflammatory Myofibroblastic Tumor (IMT) is a rare benign pseudosarcomatous lesion, characterized by inflammatory infiltrates admixed with myofibroblastic spindle cells. Initially only pulmonary locations were described, now extra-pulmonary sites are also well recognized. We present a case of a 3 year old female child who presented with history of flank pain, abdominal mass and intermittent fever of 1 year duration. Provisional diagnosis was neuroblastoma, but it turned out to be a retroperitoneal IMT with calcification. The patient was managed with surgical resection of the tumor and post-operative treatment with steroids as part of the tumour adherent to the inferior vena cava could not be resected. IMT is an uncommon neoplasm of uncertain biological potential. Both, retroperitoneal location and calcifications are rare presentations. Complete surgical resection remains the mainstay of treatment. Possible treatment of residual and recurrent tumours could be with steroids and anti-inflammatory drugs. Selected cases may need chemotherapy, the efficacy of which is not well documented. It has close resemblance to calcific fibrous pseudo-tumour and we have presented the differentiating features from review of literature.

A case of retroperitoneal schwannoma and review of literature

The term schwannoma(also known as neurilemmoma) refers to a tumor in which the cells are derived from the neurilemma or the nerve sheath, more commonly referred to as the sheath of Schwann. A retroperitoneal location accounts for 0.3-3.2% of all primary schwannomas and 0.3-6.0% of all retroperitoneal tumors. We report the case of a 47-year-old female with a benign retroperitoneal schwannoma as a rare one.

Autoimmune pancreatitis and cholangitis.

Autoimmune pancreatitis (AIP) is part of a systemic fibrosclerotic process characterized by lymphoplasmacytic infiltrate with immunoglobulin G subtype-4 (IgG4) positive cells. It characteristically presents with biliary obstruction due to mass-like swelling of the pancreas. Frequently AIP is accompanied by extra-pancreatic manifestations including retroperitoneal fibrosis, thyroid disease, and salivary gland involvement. Auto-antibodies, hypergammaglobulemia, and prompt resolution of pancreatic and extrapancreatic findings with steroids signify its autoimmune nature. Refractory cases are responsive to immunomodulators and rituximab. Involvement of the biliary tree, termed IgG4 associated cholangiopathy, mimics primary sclerosing cholangitis and is challenging to manage. High IgG4 levels and swelling of the pancreas with a diminutive pancreatic duct are suggestive of autoimmune pancreatitis. Given similarities in presentation but radical differences in management and outcome, differentiation from pancreatic malignancy is of paramount importance. There is controversy regarding the optimal diagnostic criterion and steroid trials to make the diagnosis. Additionally, the retroperitoneal location of the pancreas and requirement for histologic sampling, makes tissue acquisition challenging. Recently, a second type of autoimmune pancreatitis has been recognized with similar clinical presentation and steroid response though different histology, serologic, and extrapancreatic findings.

Blunt renal trauma in children with pre-existing renal abnormalities.

The kidneys are the most commonly injured genitourinary organ in children following blunt abdominal trauma. Though the retroperitoneal location affords the kidneys some protection from the forces experienced in blunt abdominal trauma, the kidneys are at greater risk of injury when a disease process exposes them from their normal shielded location. In such cases, the injuries may appear to be disproportionate in relation to the severity of the trauma history, confusing the imaging findings. Recognition of both the underlying disease process as well as the manifestations of acute trauma is important; therefore, we present a pictorial essay of traumatized kidneys in children with pre-existing renal abnormalities.