RETROPERITONEAL MASS :

ETIOLOGY & EVALUATION

DR. MD. SHALEH MAHMUD

RESIDENT,UROLOGY
PHASE- A, Y- 2
BSMMU
 CONTENTS

Retroperitoneal anatomy
 Etiology
 Clinical features
Investigations
Common retroperitoneal masses
RETROPERITONEAL ANATOMY
 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
 SPACES & CONTENTS

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, ner ves
CAUSES OF RETROPERITONEAL
SWELLING
Solid Neoplastic Retroperitoneal mass
Solid tumor from other
sites:
 Lymphoma
 Metastatic germ cell tumor
 Renal & Adrenal Neoplasm
 Pancreatic Neoplasm
 Colonic Neoplasm
Cystic Neoplastic Retroperitoneal mass

Neurilemoma
Non- Neoplastic Retroperitoneal mass
Solid Cystic
Retroperitoneal fibrosis Hematoma
( ORMOND’S Disease)
Urinoma

Psoas Abscess

Pseudocyst

Others : Abdominal aorta aneurysm

CLINICAL PRESENTATION
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.
 SYMPTOMS AND SIGNS OF
RETROPERITONEAL MASS

 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

 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.
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
 Constitutional symptoms:

 Fatigue
 Weakness
 Fever
 Loss of Appetite
 Loss of weight
 Back Pain
 INVESTIGATIONS FOR
RETROPERITONEAL MASS
 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.
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
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.
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.
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
1) LIPOSARCOMA:
well differentiated liposarcoma
showing huge heterogeneous mass
with predominantly fat attenuation.

2) LIPOMA: T1 weighted MRI.

Homogenous high signal intensity
mass.
 LYMPHOMA

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 NHL
in 25% with Hodgkin lymphoma
and 55% with non-Hodgkin
lymphoma.
 TERATOMA

 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-dif ferentiated 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
 RETROPERITONEAL HEMATOMA

 Caused by tr a u ma , b lood d ys cr a s i a ,
a n ticoa gu l a ti on the r a py , ru p t u re of a n
a b d omi n a l a or t i c a n e u r ys m , o r in te r ve n t ion a l or
s u r gi ca l p roce d u re s .

 Oc c asio nally, the heterogeneo us ap p earanc e o n

CE - CT images c an be c o nfused w ith a sarco ma

 t h e well -d e f in e d m a r gi n ,
 t h e a b s e n ce of con tr a s t e n h a n ce me n t ,
 t h e cha n gi n g a p p e a r a n ce w i th ti me ,
 a p rog re s s ive d e cre a s e i n s i ze ,

… . . d istinguish retroperitoneal hema to ma from

sarco ma

 low signal intensity o n M R images b ec ause o f

hemo siderin depo sitio n.
 URINOMA

 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
 RETROPERITONEAL FIBROSIS

 A fibro-inflammator y mass envelops and

potentially obstructs retroperitoneal
structures.

 Fibrous, whitish plaque encases aor ta, 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