MDCT signs differentiating retroperitoneal and

intraperitoneal lesions- diagnostic pearls

Poster No.: C-0987

Congress: ECR 2015
Type: Educational Exhibit
Authors: D. V. Bhargavi, R. Avantsa, P. Kala; Bangalore/IN
Keywords: Abdomen, CT, Diagnostic procedure, Education and training
DOI: 10.1594/ecr2015/C-0987

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Learning objectives

The diagnosis of retroperitoneal lesions is challenging which includes lesions from the
retroperitoneal organs and lesions outside the major organs.

• To differentiate and diagnose retroperitoneal lesions and Intraperitioneal

lesions based on signs on MDCT.
• To demonstrate various signs on MDCT to differentiate lesions from the
retroperitoneal organs and primary retroperitoneal lesions.
• To present an approach for the diagnosis of retroperitoneal lesions on
MDCT.

Background

Introduction

The retro peritoneum is the portion of the abdomen located posterior to the peritoneal
cavity extending from the diaphragm to the pelvic inlet . It includes portions of the colon,
duodenum, pancreas, kidneys, adrenal glands, abdominal aorta, inferior vena cava,
lymph nodes, fat and much of the abdominal wall musculature.

The retro peritoneum is commonly divided into three spaces by the anterior and posterior
renal fasciae:

1. Anterior pararenal space

2. Perirenal space
3. Posterior pararenal space

Psoas compartment is sometimes considered a fourth retroperitoneal space.

The anterior, posterior and lateroconal fasciae are often not seen as distinct layers
but instead as a multilayered complex, hence the localization of the lesion into specific
compartments is sometimes difficult.

The computed tomography can demonstrate important characteristics of these tumors.

Even then the diagnosis is often challenging for radiologists. Diagnostic challenges
include precise localization of the lesion, organ of origin, determination of the extent of
invasion, and characterization of the specific pathologic type.

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Retroperitoneal lesions can either from the retroperitoneal organs or primary
retroperitoneal lesions. Primary retroperitoneal mass lesions are a diverse group of
lesions that arise within the retroperitoneum but outside the major organs.

Images for this section:

Fig. 1: sectional anatomy of normal Retroperitoneal structures, fascial planes and

spaces.

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Fig. 2: Normal sectional anatomy of Retroperitoneum.

Fig. 3: Line diagram of Retroperitoneal structures, fascial planes and spaces.

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Fig. 4: Axial CECT images at different levels showing normal Retroperitoneal structures.

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Findings and procedure details

We retrospectively studied 25 patients with abdominal mass lesions and subsequently

confirmed with surgical and histopathological diagnoses of retroperitoneal and
intraperitoneal (IP) mass lesions. The cases included were retroperitoneal sarcomas,
renal cell carcinoma, suprarenal lesions, mesenteric mass and GIST.

Approach to retroperitoneal (RP) lesions:

Step 1. Intraabdominal or Retroperitoneal (figure 5)

Ø The retroperitoneal lesion due to its location tends to show mass effect on the adjacent
retroperitoneal structures.
Ø Lateral or anterior displacement of the retroperitoneal structures or compression over
the retroperitoneal structures.

Case 1 (figure 6)

A 35 year old male presented with abdominal mass. There is displacement of the superior
mesenteric vessels.

The lesion is identified as right renal mass and was pathologically proven to be a RCC.

Case 2 (figure 7)

A 42 year old male patient with a mass in the left posterior pararenal space displacing
the left kidney anteromedially. The mass was diagnosed as retroperitoneal sarcoma.

Case 3 (figure 8)

A 55 years old patient with left lower pole renal cell carcinoma showing displacement of
the ascending colon anteriorly.

Case 4 (figure 9)

The pancreas is seen displaced anteriorly by the prevertebral mass in a 40 year old
female patient which was diagnosed as retroperitoneal lymphoma.

Case 5 (figure 10)

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The pancreatic tail mass lesion displacing the ascending colon anteriorly.

Case 6 (figure 11)

Psoas mass lesion seen displacing the aorta anteriorly.

Step 2 - Primary retroperitoneal lesions (figure 12)

Primary retroperitoneal lesions are the lesions within the retroperitoneum but outside the
retroperitoneal structures.

Ø They have to be suspected if the lesion is displacing the retroperitoneal structures

anteriorly
Ø According to the pattern of the spread like encasement of the aorta, growth along the
paraspinal region and along the normal structures.

Pattern of spread and Infiltration of the retroperitoneal structures

Case 7 (figure 13)

Sagittal CT image of a 35 year old male patient with retroperitoneal lymphoma

demonstrating encasement and infiltration of the inferior vena cava by the mass.

Case 8 (figure 14)

Sagittal CT image of a 35 year old male patient with retroperitoneal lymphoma

demonstrating encasement of the right ureter.

Case 9 (figure 15)

Retroperitoneal mass lesion seen encasing and infiltrating the left ureter causing left
hydroureteronephrosis.

Floating aorta sign:

Floating aorta sign: encasement of aorta by retroperitoneal mass.

Case 10 (figure 16)

A 38 years old male patient with retroperitoneal lymphoma showing encasement of the
aorta by the retroperitoneal mass.

Step 3-Retroperitoneal lesions from retroperitoneal structures. (figure 17)

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There are four different signs on MDCT which aid in identifying the origin of the lesion.

Ø Beak sign: Beak deformation of edge of adjacent organ

Ø Phantom organ sign: Obscuration of small organs by large mass.
Ø Embedded organ sign: Part of organ of origin is embedded in the mass with adjacent
desmoplastic reaction .
Ø Prominent feeding artery sign: Feeding artery to the lesion arises from the organ
of origin.

Beak sign

Case 11 (figure 18)

Axial CT image of left renal cell carcinoma demonstrating beak shaped deformation at
the edge of the left kidney.

Case 12 (figure 19)

Beak sign demonstrated in a case of pancreatic tail mass lesion.

Case 13 (figure 20)

Sagittal CT image demonstrating beak sign in case of renal cell carcinoma.

Phantom organ sign

Case 14 (figure 21)

Axial CT image of a case of pheochromocytoma. Left adrenal gland is not visualized.

Embedded organ sign

Case 15 (figure 22)

Axial CT image of right renal cell carcinoma showing compression of the right kidney
by the mass . The right kidney appears embedded within the mass with desmoplastic
reaction at the contact surface.

Case 16 (figure 23)

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Sagittal CT image of a case of left psoas abscess demonstrating embedded organ sign

Prominent feeding artery sign

Case 17 (figure 24)

Axial CT image of right renal cell carcinoma showing the mass being supplied by the
right renal artery.

Case 18 (figure 25)

The retroperitoneal pancreatic mass showing its arterial supply from the celiac artery .

Step 4-Intraperitoneal lesions (figure 26)

Points aid in diagnosis of intraperitoneal lesions

Ø Identifying organ of origin
Ø Mass effect on the adjacent structures
Ø Growth within the peritoneal cavity
Ø Posterior displacement of the retroperitoneal structures.

Case 19 (figure 27)

A 42 year old patient with gastrointestinal stromal tumour with mass effect on
intraperitoneal structures- spleen, small bowel, liver.

Case 21 (figure 28)

Coronal and Sagittal CT images of a mesenteric mass within peritoneal cavity, anterior
to aorta, IVC and mass effect on urinary bladder and small bowel.

Case 22 (figure 29)

Axial and sagittal CT images of a mesenteric mass lesion deforming the shape of liver
and causing posterior displacement of aorta and kidney.

Flowchart to approach the retroperitoneal/intraperitoneal lesions. (figure 30)

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Images for this section:

Fig. 5: Step 1. identify the lesion whether it is Intra-abdominal or Retroperitoneal.

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Fig. 6: Axial CECT image in arterial phase demonstrating displacement of the superior
mesenteric vessels by the right renal mass.

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Fig. 7: Axial CECT image showing a mass in the left posterior pararenal space displacing
the left kidney anteromedially.

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Fig. 8: Thin section axial CT images showing displacement of the ascending colon
anteriorly by a mass in the left kidney lower pole.

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Fig. 9: Axial CECT image showing pancreas displaced anteriorly by the prevertebral
mass.

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Fig. 10: Axial CECT image showing the pancreatic tail mass lesion displacing the
ascending colon anteriorly.

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Page 16 of 35
Fig. 11: Sagittal CECT image showing Psoas mass lesion displacing the aorta anteriorly.

Fig. 12: Step 2 - Identifying Primary Retroperitoneal lesions.

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Fig. 13: Sagittal CECT image demonstrating encasement and infiltration of the inferior
vena cava by the mass

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Fig. 14: Axial CECT image demonstrating encasement and infiltration of the right ureter
by the mass.

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Page 20 of 35
Fig. 15: Oblique sagittal CECT image demonstrating encasement and Infiltration of the
left ureter by the mass causing left hydroureteronephrosis.

Fig. 16: Axial CECT images showing encasement of the aorta by the retroperitoneal mass

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Fig. 17: Step 3-Identifying retroperitoneal lesions arising from retroperitoneal structures.

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Fig. 18: Axial CECT image of left renal cell carcinoma demonstrating beak shaped
deformation at the edge of the left kidney.

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Fig. 19: Axial CECT image with beak sign demonstrated in a case of pancreatic tail mass
lesion.

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Fig. 20: Sagittal CECT image demonstrating beak sign in case of renal cell carcinoma.

Fig. 21: Axial CECT image of a case of Pheochromocytoma . Left adrenal gland is not
visualized.

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Fig. 22: Axial CECT image of right renal cell carcinoma showing compression of the
right kidney by the mass . The right kidney appears embedded within the mass with
desmoplastic reaction at the contact surface.

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Page 28 of 35
Fig. 23: Oblique sagittal CECT image of a case of left psoas abscess demonstrating
embedded organ sign.

Fig. 24: Axial CECT image of right renal cell carcinoma showing the mass being supplied
by the right renal artery.

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Fig. 25: Axial CECT image showing the retroperitoneal mass being supplied by the celiac
artery .

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Fig. 26: Step 4-Identifying Intraperitoneal lesions

Fig. 27: Coronal and sagittal CECT images showing mass effect on intraperitoneal
structures- spleen, small bowel, liver.

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Fig. 28: Coronal and Sagittal CECT images of a mesenteric mass within peritoneal cavity,
anterior to aorta, IVC and mass effect on urinary bladder and small bowel.

Fig. 29: Axial and sagittal CECT images of a mesenteric mass lesion deforming the shape
of liver and causing posterior displacement of aorta and kidney.

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Fig. 30: Flow chart-Approach for diagnosis of intraperitoneal/retroperitoneal lesions.

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Conclusion

Reliable differentiation between intra and retroperitoneal lesions can be made using a
specific approach pattern and various MDCT signs.

Personal information

Dr Vidya Bhargavi,

Resident, Department of radiology,

Vydehi institute of medical sciences, Bangalore, India.

Dr Rohini Avantsa, MD.

Sectional Imaging Division, Department of radiology,

Vydehi institute of medical sciences, Bangalore, India.

rkgayatri5@gmail.com

Dr Prachi Kala, MD.

Sectional Imaging Division, Department of radiology,

Vydehi institute of medical sciences, Bangalore, India.

References

1.Mzuki Nshino, Katsumi Hayakama, Manabu Minami , et al . Primary retroperitoneal

neoplasms: CT and MR imaging findings with anatomic and pathologic diagnostic clues .
Radiographics 2003; 23:45-57.

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2- Engelken , Ros , Retroperitoneal MR imaging . Magnetic resonance imaging clin N
Am 1997; 5:165-178.

3-Scanlan DB . Primary retroperitoneal tumour . J Urol 1959;81:740

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