primary retroperitoneal tumor
Introduction
Introduction to primary retroperitoneal tumor Primary retroperitoneal tumor refers to various soft tissue tumors from the retroperitoneal space, but does not include tumors of the retroperitoneal organ. It can be divided into benign and malignant types. According to foreign reports, malignant tumors account for about 80%, and domestically, 56%. Retroperitoneal tumors have biological characteristics such as swelling growth, complete capsule, difficulty in metastasis, and local recurrence. Because the tumor site is deep, there is a certain room for expansion, and there is no symptom at the early stage of the disease. Therefore, early diagnosis has certain difficulties. As the tumor grows, oppresses or invades the surrounding organs and tissues, symptoms appear, which adds to the thorough treatment. The difficulty. basic knowledge The proportion of illness: 0.003% Susceptible people: no specific population Mode of infection: non-infectious Complications: anemia hypokalemia nausea and vomiting diarrhea abdominal pain acute peritonitis shock
Cause
Primary retroperitoneal tumor etiology
(1) Causes of the disease
The retroperitoneal tumor mainly originates from the fat in the retroperitoneal space, loose connective tissue, fascia, muscle, blood vessels, nerve tissue, lymphoid tissue and embryonic residual tissue, and 2/3 is a malignant tumor.
Benign tumor
Lipoma, fibroids, ganglioneuroma, cystic teratoma, and chemoreceptor tumors.
2. Malignant tumor
Lymphosarcoma, liposarcoma, fibrosarcoma, malignant schwannomas and malignant teratoma.
(two) pathogenesis
There are many types of primary retroperitoneal tumors. The most common tumors usually originate from the retroperitoneal kidney, the adrenal gland and various soft tissues behind the retroperitoneum.
1. Pathological classification: According to histopathological classification, primary retroperitoneal tumors mainly include soft tissue tumors, germ cell tumors, lymphoid hematopoietic tumors, kidney tumors, adrenal tumors, metastatic tumors and other rare tumors, according to biological behavior. There are two major categories, benign and malignant. According to their origin, there are many tissues such as mesoderm, nervous tissue, genitourinary system and embryonic remnant.
More malignant tumors than benign tumors, accounting for about 80%, of which malignant lymphoma is the most common, followed by fibrosarcoma, liposarcoma, undifferentiated sarcoma, leiomyosarcoma and rhabdomyosarcoma, neurogenic sarcoma is also more common, common Benign tumors include lipoma, lymphoma or chyle cysts, nephrogenic cysts, dermoid cysts and enterogenous cysts.
The tumor can be solid, cystic or mixed, the color varies depending on the source of the tumor tissue, the fibroid is white, the lipoma is yellow, the sarcoma is pink or red, and the tumor can be single or multiple, and the size can vary greatly. Generally speaking, cystic tumors are mostly benign, while solid tumors are often malignant. There are often small tumor tissues around the main body of the tumor, or small tumor tissues are connected with the tumor body by small pedicles. Or easy to be ignored, causing postoperative recurrence.
2. Pathological features: The pathological features of common retroperitoneal tumors are:
(1) Soft tissue tumors: including tumors of origin such as fat, nerve, fiber and muscle tissue, among which fat-derived tumors are the most common, especially liposarcoma.
1 fat-derived tumor:
A. Retroperitoneal sarcoma (liposarcoma): 12 to 43% of retroperitoneal tumors occur well around the kidneys. In most cases, large isolated tumors are more than 4 cm in diameter. In a few cases, multiple isolated knots can be expressed. Section, liposarcoma has irregular shape, lobulated shape, clear boundary, and there are capsules. Some of the cut surfaces are grayish yellow and resemble lipomatous; some are grayish white or brownish red, soft like fish meat; some cut surfaces are moist It is jelly-like translucent, soft or partially flexible. There are different stages of fat cells in different stages of tumor observation. The interstitial contains fibrous mucoid-like components, which occur in the retroperitoneal fat sarcoma. The prognosis of liposarcoma in the limb is poor.
Histological classification of retroperitoneal liposarcoma includes differentiated liposarcoma (highly differentiated liposarcoma), mucinous liposarcoma, round cell liposarcoma, spindle cell liposarcoma, pleomorphic liposarcoma and dedifferentiated liposarcoma, in which differentiation Type liposarcoma includes lipoma-like liposarcoma, sclerosing liposarcoma and inflammatory liposarcoma. Histologically, liposarcoma has simulated fat cells from primitive mesenchymal cells to fat cells to well-differentiated fat cells. Characteristics, the majority of retroperitoneal liposarcoma is highly differentiated liposarcoma, its histological morphology is mainly composed of nearly mature fat cells, but it can be seen that fat cells containing small lipid droplets and fusiform, nuclear large stained cells Sclerosing liposarcoma on the basis of the above-mentioned lesions, obvious fibrous tissue hyperplasia and vitreous changes occur in the tumor; inflammatory liposarcoma morphology in addition to the characteristics of sclerosing liposarcoma, there are a large number of lymphocytes and plasma in the tumor tissue Cell-based inflammatory cells infiltrate.
B. retroperitoneal lipoma (lipoma): retroperitoneal lipoma is much less common than liposarcoma, round or oval, lobulated, soft, enveloped, pale yellow in cut surface, histological features of tumor tissue It is composed of mature fat cells, which contain fibrous tissue, blood vessels and mucin-like tissues, no fat cells, and any fat-derived tumors that occur after the retroperitoneum. When tumor cells have atypical characteristics, no matter how limited the tumor is. All should be diagnosed as well-differentiated liposarcoma, because such adipose-derived tumors have a significant tendency to relapse, and long-term follow-up suggests a poor prognosis.
2 fibrous tissue-derived tumors:
A. malignant fibrous histiocytoma accounts for the second place of retroperitoneal sarcoma. The tumor is large in volume, more than 5cm in diameter, no capsule, clear boundary, nodular or lobulated, moderate hardness. The cut surface is grayish white or grayish red, common hemorrhage, necrosis and cystic change. The typical histological feature is that the tumor tissue is composed of tissue cells and inflammatory cells. The tissue cells are mainly fusiform fibroblasts and oval tissues. Cells, etc., inflammatory cells are mainly lymphocytes, and plasma cells and neutrophils are few. Fibroblasts are often arranged in a car-like shape. The cytoplasm of tissue cells is rich in lipids and vesicles, and the nucleus is large and deformed. The nucleolus is obvious, and the pathological mitosis is more common. If the vascular-like matrix mucus-like change in the tumor tissue exceeds 1/2 of the tumor, it is called mucinous malignant fibrous histiocytoma. When there is a large amount of bone breakage in the tumor tissue. Multinucleated giant cells, accompanied by focal bone or bone-like tissue, are called giant cell type malignant fibrous histiocytoma, such as a large number of yellow tumor cells in the tumor tissue, accompanied by a large number of acute and When the inflammatory cells (including neutrophils, lymphocytes, plasma cells, and eosinophils), wherein the inflammatory cells accounted for 5% to 10% of the tumor, called xanthomas type (inflammatory) malignant fibrous histiocytoma.
B. Renal angiomyolipoma: is a benign tumor of the retroperitoneum. Because its smooth muscle cell morphology is often atypical, it is easily confused with leiomyosarcoma in biopsy specimens. It is mature around the renal hilum. Fat and thick-walled blood vessels, as well as bundled, atypical smooth muscle cell-based tumors, immunohistochemically labeled tumor cells expressing melanoma monoclonal antibody (HMB45), support the diagnosis of angiomyolipoma, of course A small number of malignant angiomyolipomas have been reported. In addition to the atypical pattern of smooth muscle cells, there must be more pathological mitotic figures, tumor necrosis and infiltration of surrounding tissues or surrounding (distant) metastasis.
C. Retroperitoneal rhabdomyosarcoma (rhabdomyosarcoma): limited to infants and children, histologically usually embryonic (embryonal rhabdomyosarcoma), characterized by a generally edematous, soft, grape-like mass, no capsule, clear boundaries Grayish white or red, the cut surface is fish-like, visible mucus-like area and hemorrhage, necrosis, microscopic examination: the tumor tissue is composed of undifferentiated fusiform and small round cells, mixed with well-differentiated rhabdomyoblasts, tumor cells Disperse or small nested in the loose mucus matrix, spindle cells are mostly located in the center or partial position of the cell, the cell boundary is clear, the nucleus is fusiform, deep stained, mitotic figures are more common; cytoplasm is less, eosinophilic, The cytoplasmic processes are interconnected with a star-shaped shape, small round cells, large nuclei, round, deep staining, mitotic figures, less cytoplasm, and abundant interstitial blood vessels.
4 fibrogenic tumors: solitary fibrous tumors can be primary in the retroperitoneum, clinically benign, sometimes accompanied by hypoglycemia.
A. fibromatosis: retroperitoneal fibromatosis, sometimes involving the mediastinum, the mass is mainly composed of fibroblasts and a large number of collagen fibers, the tumor cells are arranged in bundles, crisscross, and idiopathic retroperitoneal fibers The difference is that, in addition to lymphocytic infiltration around the blood vessels at the edge of the lesion, the tumor parenchyma lacks obvious inflammatory components.
B. Fibrosarcoma (fibrosarcoma): is one of the rare retroperitoneal malignant tumors, its volume is generally large, there is a capsule, the quality is hard, the cut surface is grayish white, fish-like, often necrotic, cystic changes, microscopic examination: The tumor tissue is composed of fibroblasts, arranged in bundles or braided. The well-differentiated tumor cells have small atypia, fewer mitotic figures, and more collagen fibers between the tumor cells. The poorly differentiated tumor cells are heterogeneous, with many mitotic figures and tumors. There are few collagen fibers between cells, and giant cells can be seen.
5 vasculogenic tumors: vascular tumors occurring after the retroperitoneum include hemangioma, vascular endothelial cell tumor, vascular epithelioma, lymphangioma, lymphangioma and angiosarcoma, etc., histological morphology and soft tissue The corresponding tumor is similar.
Hemangioendothelioma, which occurs in infants, is a unique subtype of vascular tumors. This disease is a low-grade malignant or borderline tumor that is prone to retroperitoneal, clinically and often accompanied by thrombocytopenia and bleeding tendency (Kasabach) -Merritt syndrome), histological morphology mainly consists of heterotypic fusiformoma cells with fissure-like or cavernous hemangioma-like structures and lymphocytes, plasma cells.
6 Neurogenic tumors: Benign retroperitoneal peripheral nerve tumors are rarer than those occurring in mediastinum. Both schwannomas and neurofibromas are reported. Retroperitoneal malignant peripheral nerve tumors are relatively common. Tumors can directly invade bone tissue and undergo extensive metastasis. Sympathetic tumors that are common in the adrenal gland can also occur in the retroperitoneum outside the adrenal gland, including neuroblastoma, ganglion cell neuroblastoma, ganglioneuroma, and tumors of various variants, about 10% of the accessory ganglia. Tumors occur outside the adrenal gland. Tumors can occur anywhere along the midline of the retroperitoneum. Some of the retroperitoneal stromal tumors can present epithelial-like morphology, or appear as focal granule cell changes, some of which The ultrastructure of the stromal tumor suggests a feature of neural differentiation.
(2) Germ cell tumors: retroperitoneal germ cell tumors are more common in men, mainly in children, mainly mature teratoma and immature teratoma, yolk sac Tumor (yolk sac tumor) and embryonal cancer, which can occur in adults, can also be metastatic from gonadal germ cell tumors. The histological types of tumors include seminal tumors (seminoma), embryonal cancer, and maturation. And immature teratoma, malignant transformation of mature teratoma, yolk sac tumor and chorionic epithelial carcinoma (chorioepithelioma), in male, retroperitoneal metastatic germ cell tumor from the same type of testicular primary tumor than in the mediastinum The incidence of tumors is much higher. The primary and metastatic germ cell tumors in the retroperitoneal are different in general morphology. Generally, the primary tumors in the retroperitoneal tumor form a single tumor, while those transferred from the testicle tend to form multiple tumors. Nodules, and often located on the posterior side of the retroperitoneum. In addition, the primary cause of seminoma is larger than other types of germ cell tumors. In some cases, only small tubes can be seen in the testes. Germ cell tumors (ie, carcinoma in situ), therefore suggesting that retroperitoneal tumors may be unrelated, that is, non-testicular germ cell tumor metastasis.
(3) Other rare types of tumors after retroperitoneal:
1 myofibroblastoma: also known as inflammatory myofibroblastoma or vascular myofibroblastoma or inflammatory pseudotumor, etc., this tumor is generally considered benign, but in recent years there have been reports of malignant myofibroblastoma .
2 Myelodystical lipoma similar to adrenal gland: can occur in the anterior tibial region, the tumor is clear, the tumor can be huge, histology is composed of adipocytes and normal bone marrow hematopoietic tissue, the tumor is often asymptomatic, but When extramedullary hematopoietic components form tumors (lack of fat, unclear boundaries), they may be associated with myeloproliferative diseases, hemolytic anemia, or severe bone diseases.
3Müllerian epithelial tumors: Primary Müllerian epithelial tumors are occasionally seen in the retroperitoneum of the pelvic or rectal vaginal septum. These tumors may be benign or malignant, with histological morphology of serous, mucinous or endometrial. Cystic or cystic gland tumors formed by epithelial cells, which originate from ectopic ovarian tissue or from mesenchymal metaplasia with the peritoneal mesothelial layer. If the tumor is composed of endometrial epithelium, it is often combined with intrauterine Membrane ectopic disease, some of the retroperitoneal mucinous tumors are characterized by gastric mucosal epithelial differentiation, suggesting that the tumor occurs in a completely different tissue.
4 Extrarenal retroperitoneal Wilms tumors lacking teratoma: some of them may be teratogenic tumors composed mainly or completely composed of kidney tissue. Most of the retroperitoneal Wilms tumors occur in children, but there are also cases reported in adults. .
Category 5 cancer: has been reported as a retroperitoneal primary tumor, but whether it is from the metastasis of the unidentified primary site, or the teratoma of the single germ layer, or the endocrine cells normally distributed in the retroperitoneum The tumor has yet to be determined by further research.
6 retroperitoneal myoepithelial neoplasia: its histological morphology is similar to schwannomas, usually require immunohistochemical markers to confirm the diagnosis.
Prevention
Primary retroperitoneal tumor prevention
The disease is a primary tumor and there are no effective preventive measures.
Complication
Primary retroperitoneal tumor complications Complications anemia hypokalemia nausea and vomiting diarrhea abdominal pain acute peritonitis shock
1. Anemia: Tumor bleeding or a retroperitoneal tumor in children grows faster and can cause anemia.
2. Hypokalemia: When the tumor is large, when the gastrointestinal tract is pushed or pressed, the patient may suffer from loss of appetite, nausea and vomiting, diarrhea, etc., causing a large loss of potassium and insufficient supplementation, resulting in a decrease in blood potassium and a disorder of serum electrolytes.
3. Acute peritonitis: When the tumor ruptures, the blood may stimulate the peritoneum to have symptoms and signs of abdominal pain, abdominal muscle tension, tenderness, rebound tenderness and other acute peritonitis.
4. Low-volume shock: When the tumor ruptures or invades the large blood vessels, it can cause a lot of bleeding, and low-volume shock occurs.
Symptom
Primary retroperitoneal tumor symptoms Common symptoms Nausea bloating Constipation Low fever Abdominal mass Back pain Bloody dyspnea Abdominal wall venous jaundice
Because the organs associated with retroperitoneal tumors are buried in the retroperitoneal wide, loose connective tissue gap, before the appearance of clinical signs and symptoms, the tumor can occult in this cavity and grow around, and is not easily blocked, so early Often asymptomatic, until the tumor grows to a considerable extent, will produce symptoms, but not serious, the symptoms and signs often associated with the displacement and obstruction of the relevant organs (due to tumor compression), due to retroperitoneal tumors The source and location of the tissue are different, and its clinical manifestations are diverse, but there are also some common symptoms and signs.
1. Abdominal mass: In the early stage, unless the patient inadvertently or when the doctor finds a tumor, it is usually found when the tumor grows to a considerable extent. The tumor is mostly on the upper abdomen or upper abdomen and begins to occur in the lower abdomen. There are fewer, but often the tumor develops to occupy the retroperitoneal space and it is not easy to determine the primary site. The knees and elbows are used to palpate the tumor without palpation and the anterior wall of the abdomen has a gong. It can be proved that the tumor is located in the retroperitoneum, but Most of the tumors have a voiced voice in the anterior wall of the abdomen. If the tumor can be promoted, most of them are benign, such as fixed, hard and unclear borders, mostly malignant, some cystic tumors can be hard, and some solid tumors can be like capsules. Sex, such as lipoma, can even be misdiagnosed as ascites, palpation alone, it is difficult to determine its benign and malignant according to its size, hardness, retroperitoneal tumors generally no tenderness, a few have light tenderness, malignant tumor center necrosis, bleeding, In the case of secondary infection or rupture, the tenderness is obvious, and the abdominal muscles are tense, and there is rebound tenderness and fever. These conditions are more common in the advanced stage of the tumor. The peritoneal tumor is often diagnosed as a normal bowel sound, and some tumors are bulged. knock Voiced sound or solid form, and at its side percussion drum sound, suggesting intestine is pushed to one side, a small number of patients with ascites, but often difficult to knock out, normal or slightly auscultation bowel sounds hyperthyroidism.
2. Abdominal distension: The main reason is the enlargement of the tumor, the degree of which is mostly parallel with the tumor growth, so there is no sensation of bloating in the early stage, and the patient gradually develops a feeling of bloating with the enlargement of the tumor, but the diffuse drum sound is percussed with the intestinal obstruction. Different, there is no mobile dullness of ascites. In some cases, intestinal obstruction or ascites is the exception. Because the gastrointestinal tract is displaced, it is often heard on the upper or side of the tumor. The peristalsis is normal or slightly hyperactive.
3. Abdominal pain: Most patients have a feeling of bulging in the abdomen, heavy feeling or discomfort, which can last for several months or even years, especially benign tumors. Abdominal pain occurs with the course of the disease, mostly pain or pain, and a few patients suffer from severe pain. It is often caused by malignant tumors eroding adjacent organs or nerves, tumor rupture, bleeding or intestinal obstruction can suddenly cause acute abdominal pain, signs of peritoneal irritation and shock, etc., the location of abdominal pain is more likely to be the location of the tumor, in addition, if there is a back Pain, mostly caused by malignant tumors invading the posterior abdomen wall. After the tumor invades the lumbar nerve, there may be pain or numbness on one or both sides of the lower extremity.
4. The involvement of adjacent organs: the symptoms caused by the retroperitoneal tumor pushing and invading adjacent organs. In benign tumors, most of them are mechanically pushed or directly compressed. Malignant tumors can directly invade nearby organs and cause symptoms. Adjacent organ involvement mainly includes the following:
(1) gastrointestinal involvement can cause loss of appetite, nausea and vomiting, diarrhea, constipation, gastrointestinal pressure can be obstructed.
(2) portal vein or hepatic vein pressure obstruction, can cause extrahepatic portal hypertension, internal hemorrhoids and umbilical varices, and even esophageal and gastric varices, and can rupture hematemesis and blood in the stool.
(3) Obstructive jaundice occurs when the common bile duct is compressed.
(4) renal compression can be displaced, ureter and bladder compression can occur ureteral dilatation and hydronephrosis; can also occur frequent urination, urgency, dysuria, hematuria, urinary closure and even uremia.
(5) retroperitoneal large veins following vena cava or iliac vein and lymphatic vessel compression, can occur in the inferior vena cava or iliac vein thrombosis, lower extremity edema, varicose veins, phlebitis, abdominal wall venous engorgement, varicocele, and even Misdiagnosed as simple varicocele for surgery.
(6) penile and scrotal edema may occur in the retroperitoneal tumor of the pelvic cavity.
(7) The compression of the lumbar nerve can cause radiation pain in the posterior side of the lower limb.
(8) Neuroblastoma can occur such as eyelids, skull, long bones and liver.
(9) The diaphragm is pushed up, pleural stimulation and pleural effusion, lung metastasis, etc. can cause difficulty in breathing.
5. Other manifestations: In addition to the above main clinical manifestations, due to the different tissue sources and pathological types of retroperitoneal tumors, the following special diseases may occur, such as abdominal tumors in young children and children, which grow faster, and the tumor is fixed and accompanied Most of the symptoms such as fever and anemia are malignant tumors of the retroperitoneal space or organs, such as neuroblastoma, teratoma, embryonal sarcoma, abdominal malignant lymphoma, etc., benign tumors and cysts are more common in women, and anterior notochord Tumors are more common in men, pheochromocytoma has high blood pressure, some have retroperitoneal sarcoma and diarrhea with hypokalemia, bloating, weight loss and high blood pressure, and some retroperitoneal tumors may be associated with lipoma or liposarcoma in other areas. Multiple neurofibromatosis, multiple colon polyposis.
Examine
Examination of primary retroperitoneal tumors
Laboratory inspection
Blood routine
(1) Hemoglobin: necrosis of the center of the malignant tumor, hemorrhage, or a rapid growth of the retroperitoneal tumor in children may be accompanied by a decrease in hemoglobin.
(2) White blood cell count: There may be an increase in the total amount of white blood cells in the retroperitoneal tumor necrosis or secondary infection.
2. Histopathological examination should be diagnosed by other methods before surgery, if necessary, laparotomy or laparoscopic surgery for biopsy.
3. Immunohistochemical markers
(1) Angiomyolipoma expresses a melanoma monoclonal antibody (HMB45).
(2) S-100 positive expression of schwannomas; chromogranin A, S-100 protein, beta-endorphin molecule positive expression; positive expression of cytokeratin in chordoma cells, positive expression of tumor vimentin and S-100 protein.
(3) leiomyomas and leiomyosarcoma desmin, muscle actin positive; myoepithelial histological morphology is similar to schwannomas, also need immunohistochemical markers to confirm the diagnosis.
Film degree exam
X-ray inspection
(1) Abdominal fluoroscopy: It can be seen that the diaphragm is pushed up by the tumor, the activity is reduced, or the pleural effusion or lung metastasis can be seen in the chordoma, pelvic malignant teratoma, meningioma or neurogenic primary tumor. It can be seen that the bone adjacent to the tumor is eroded, destroyed or deformed.
(2) Abdominal plain film: Most of the retroperitoneal tumors are positive in the abdomen. Lateral X-ray examination shows that there is a soft tissue block in the abdomen or a higher transparency of lipoma and liposarcoma. Some skin-like cysts have different shadow densities. Mature bone, teeth or calcification are characteristic of teratoma, but common calcification spots can be found in a variety of tumors such as neuroblastoma, ganglionoma, mixed tumor, schwannomas, neurofibroma. , chordoma, leiomyomas and intestinal material, chronic inflammation including lymph node calcification, old hematoma calcification, pancreatic lesion calcification, etc., has no special significance for diagnosis, and even hinders understanding of the nature of the tumor, abdominal plain film can be displayed The contour position of the kidney, the shadow of the psoas muscle, etc. are abnormal. The blurring of the lumbar muscles is not a special sign. In addition to the retroperitoneal tumor, it can also be seen in other diseases and without lesions. The abdominal plain film can also show the adjacent organs of the tumor. Liver, spleen, gastrointestinal shift or deformation.
(3) digestive tract angiography: gastrointestinal barium meal examination and barium enema examination can exclude gastrointestinal tumors or intra-abdominal tumors and understand the degree of gastrointestinal pressure, the gastrointestinal tract is pushed and displaced by the tumor, can determine the location of the tumor and In addition to gastrointestinal tumors, in addition, retroperitoneal organs such as pancreatic or renal cysts, large tumors and intraperitoneal tumors can also shift the gastrointestinal tract, which should be carefully identified.
(4) urography: the tumor located in the retroperitoneum is most likely to cause compression and invasion of the kidney and ureter, intravenous urinary tract or retrograde urography can show renal pelvis, ureteral pressure displacement and the presence or absence of expansion of effusion, etc. Judging the tumor site, understanding the urinary tract pressure and the function of the contralateral kidney, some urography of the retroperitoneal tumor can show the kidney, the ureter and even the bladder is pushed and displaced by the tumor, and the location of the tumor can be confirmed and excluded. Kidney, ureter and bladder lesions, tumors above the kidney are generally prone to renal displacement or deformation, and renal pelvis and renal pelvis can also be deformed, but adrenal tumors, huge tumors in other parts of the abdominal cavity, huge spleen or liver can also make Kidney shift, deformation, ureter is easy to be pushed and displaced by retroperitoneal tumor, but less pressure or erosion, mainly seen in malignant tumors; sometimes one side of the ureter is compressed to narrow the lumen and cause ureteral hydrops and hydronephrosis .
From the renal and ureteral displacement and functional changes, can be identified as retroperitoneal tumor or retroperitoneal fibrosis, bilateral renal function loss in the retroperitoneal fibrosis is not uncommon, but in the primary retroperitoneal tumor is rare, generally Non-functional renal retrograde intubation is possible in retroperitoneal fibrosis, whereas in retroperitoneal tumors, ureteral obstruction may be difficult to insert, sometimes retroperitoneal tumors may shift the ureter inward or outward, most retroperitoneal Fibrosis can make the ureter shift inward and be narrowed on one or both sides. In addition, the inward displacement of the right ureter is sometimes seen in the ectopic vena cava ureter; the ureter is sometimes displaced in the psoas muscle. Developed young adults, but if they move forward significantly, they are often caused by retroperitoneal tumors.
(5) angiography: mainly based on the feeding, distribution and morphological changes of the feeding artery, to determine the source of the tumor, to show the degree of vascular invasion, to find a smaller tumor, in order to facilitate the development of the surgical plan, and at the same time preoperative Chemotherapy and embolization treatment.
1 Inferior vena cava angiography: It can show the extent of tumor invasion and pushing on the vein wall. It is helpful to preoperatively design the treatment method for the affected inferior vena cava, and appropriate preoperative preparation, which occurs in the retroperitoneal right soft tissue. Or an organ tumor that may invade and deform, deform, partially or completely block, or form a thrombus. It should be noted that retroperitoneal fibrosis can also shift the inferior vena cava forward, but mainly Peripheral vena cava is characterized by peripheral stenosis or even obstruction, but significant shifts should be considered for tumors.
2 retrograde aortic angiography: aortic angiography through the femoral artery can show the location of the tumor and its vascular distribution, and thus speculate its nature, malignant tumor can invade adjacent organs, it is difficult to distinguish whether it is primary or not from the distribution of blood vessels. Secondary, in general, most benign tumors, cysts and a few malignant tumors have few or no blood vessels. Around a tumor without a blood vessel, the blood vessels are curved and often a benign tumor angiogram, if the tumor is inside Abnormal blood vessel distribution, irregular or uneven blood vessel thickness, contrast plaque in the tumor area, arteriovenous communication and abnormal images such as contrast agent venous return, and multiple angiographic signs of malignant tumor.
3 digital subtraction angiography: digital substraction angiography (digital substraction angiography) can better show the source and distribution of tumor blood vessels, rich neovascularization often indicates the existence of malignant tumors, can also understand the invasion of large blood vessels, and At the same time, vascular embolization can be performed to reduce tumor blood supply for surgery. By showing the relationship with important blood vessels and some organs, in order to correctly judge the condition, a surgical plan for resecting a huge tumor or a cystic tumor communicating with a blood vessel can be made, and the operation can be reduced. Blood loss provides an important basis.
2. Ultrasound examination can find tumors that have not been touched by the clinic, showing the location, size, number, shape and relationship with the surrounding tissues. The tissue resolution is high, the price is low, and there is no contraindication. It can be used as the first choice for retroperitoneal tumors. Methods, the diagnostic coincidence rate of 80%, can also be used for needle biopsy and long-term follow-up of the lesion, but its imaging performance is lack of characteristics, often due to the presence of intestinal gas, affecting the display of some tumors, its accuracy is relatively poor Should be considered in combination with CT or MRI examination.
(1) Location and morphology of retroperitoneal tumor: The position of the retroperitoneal tumor is deep, the posterior margin is often close to the spine, and the retroperitoneal large blood vessel is pressed or wrapped, and does not change with the breathing and position. This can be associated with intra-abdominal tumor. Identification, tumor morphology is variable, can be expressed as nodular, lobulated, elliptical or irregular shape.
(2) Boundary capsule of retroperitoneal tumor: Most malignant tumors show invasive growth and extend to adjacent tissues. The boundaries of the acoustic features are irregular and irregular. Benign tumors often have a complete capsule and are clearly separated from the surrounding.
(3) Internal echo of retroperitoneal tumor: benign tumor grows slowly, internal echo is relatively homogeneous, internal liquid dark area is regular, color blood flow is less, most malignant tumors are substantial, internal echo is heterogeneous, Color Doppler blood flow is rich, some malignant tumors grow rapidly, blood supply is insufficient, necrosis can occur, the sonogram shows uneven echo or liquid dark areas, dark areas are often irregular.
(4) Posterior retroperitoneal tumor echo: The bottom of malignant tumor often forms uneven infiltration, the acoustic image is characterized by irregular thickening of the posterior wall, and the posterior wall of benign tumor is often neat and clear.
(5) relationship between retroperitoneal tumor and surrounding organs: liver and kidney, spleen and kidney separation signs, due to the occupying position of the retroperitoneal tumor, often deform the kidney section image, the kidney forward, downward shift or overlap adhesion, observe the tumor and The relationship of these organs can help to clarify the diagnosis.
(6) Color Doppler flow performance: benign tumors have less internal blood flow and higher blood flow resistance index, while malignant tumors have more internal blood flow and lower resistance index than benign. Sheng Xiaoyang believes that patients are younger. The internal echo of the tumor is relatively homogeneous, the blood flow is rich, and the resistance index is low (RI<0.64), which can be used as a characteristic of primary malignant retroperitoneal tumor.
Diagnosis
Diagnosis and diagnosis of primary retroperitoneal tumor
diagnosis
Because the primary retroperitoneal tumor is located in the retroperitoneal space, the location is deep, and there are no obvious clinical symptoms in the early stage. It is extremely difficult to find, and the tissue origin of the primary retroperitoneal tumor, the location of the disease is different, and the clinical manifestations are diverse and lacking. Specificity, often associated with the location of the tumor and affected organs, most patients pay attention when the tumor volume grows to a considerable extent, abdominal mass, abdominal distension and abdominal pain are the first and common clinical symptoms, in addition, patients can also appear Weight loss, low fever, gastrointestinal tract, back and lower extremity pain, etc., retroperitoneal tumors located in the pelvic cavity may also have rectal, bladder compression symptoms, therefore, clinically, such as patients with abdominal mass, abdominal pain, bloating or some of the aforementioned symptoms In addition to considering common diseases or tumors in the abdominal cavity, the possibility of retroperitoneal tumors should be considered. For some suspicious signs such as varicocele, calf edema or varicose veins, abdominal varices, rectal or vaginal examination, there are tumors in the pelvis, etc. The presence or absence of tumors in the abdomen and their relationship should be further examined.
Only by clinical manifestations can not clearly diagnose the location and nature of retroperitoneal tumors, should be combined with the aforementioned clinical features, X-ray examination, abdominal ultrasound, CT scan, magnetic resonance imaging (MRI) comprehensive consideration, generally speaking, substantial and larger The tumors are mostly malignant, and may be irregularly lobulated or multi-nodular fusion, with unclear or invasive borders with surrounding tissues, and enlarged lymph nodes; angiography shows that tumor vascular hyperplasia is disordered, and "blood pool" or arteriovenous can be seen. The sacral tumors are often benign, their growth is slow, they all have intact capsules, and the edges are clear. About 85% of the mesenchymal tumors are malignant, while the neurogenic and germ cell-derived tumors are mostly benign. According to the characteristics of the tumor itself, the nature of primary retroperitoneal tumor is preliminarily determined. Generally, the course of benign tumor is longer, and the course of malignant tumor is shorter. Abdominal ultrasound shows that most of the malignant tumors have a clear boundary and are not regular. The internal echo is uneven, it is stuck and infiltrated with the surrounding organs, the contour of the tumor is irregular, it is difficult to determine the boundary, or the satellite nodules are found, and the outline of the organ is interrupted; Sexual tumors are more regular, the boundary is clear, the internal echo is more uniform, and the boundary between the surrounding organs is clear. Color Doppler can also detect the rich echo of blood in malignant tumors, while the echoes in the benign tumors have little or no blood flow. CT showed that the solid tumor showed multi-nodular fusion or irregular lobulation, and the boundary with the surrounding tissue was unclear or invasive. The lymph nodes were enlarged, mostly malignant; and the benign tumor had a complete capsule and the boundary was clear.
If necessary, a laparotomy or laparoscopic surgery may be performed to obtain a correct diagnosis by biopsy.
Differential diagnosis
1. Kidney tumor: Kidney tumor is more common in malignancy, less benign and less accessible to the abdomen. Adults are more common in kidney cancer, which occurs in children over 40 years old. The tumor is located at the waist, often with macroscopic or microscopic hematuria. Patients often have fever, anemia and weight loss, intravenous urography, abdominal ultrasound, CT scan shows lesions in the renal parenchyma, renal radionuclide scan can also help diagnosis.
Wilms tumor is a common tumor in children. The majority of cases occur in 2 to 4 years old. The tumor is located on one side of the waist and does not exceed the midline of the abdomen. It is often accompanied by fever. Half of the children have elevated blood pressure and anemia and cachexia in the late stage. Ultrasonography, CT scan showed a substantial lesion in the kidney, and intravenous urography showed a substantial lesion in the kidney or no development.
2. Hydronephrosis: congenital hydronephrosis in children due to congenital upper urinary tract obstruction, occurs in children over 5 years old, the tumor is located in the lateral abdomen, cystic, abdominal wall is thin, positive test, X-ray The film can be enlarged and sometimes visible calcification, ultrasound, excretory urography, radionuclide kidney and kidney scan are valuable for diagnosis. Adult hydronephrosis has a long history, may have hematuria, history of low back pain, some patients Due to ureteral stones, there may be a history of cramps, or a history of secondary infection, excretory urography can be seen enlarged renal pelvis, but advanced cases can not be developed, congenital or adult hydronephrosis is temporarily relieved due to obstruction And there is a history of sudden tumor shrinkage, which is a unique symptom of this disease.
3. Polycystic kidney disease: a congenital disease caused by a disorder in the connection between the renal tubules and the collecting duct in the embryonic stage. The infant type is more than one year old, and the adult type is mostly bilateral, and the onset is slow, often at 40. Symptoms appear around the age, and often accompanied by other organs such as liver, lung cysts, etc., in addition to the swelling of the waist, there may be hematuria, urinary tract infection, high blood pressure and history of side abdomen or lumbar pain, uremia may occur in the late stage, urinary tract The angiography showed signs of elongation, deformation and other signs of renal pelvis and renal pelvis. There were multiple liquid level segments in the ultrasound examination of the kidney area, and the radionuclide scan showed a large area of radioactive defect in the kidney.
4. Pancreatic cyst: The disease should be differentiated from the retroperitoneal tumor located in the upper abdomen. Clinically, pseudo-pancreatic cysts are more common. The course of the disease is longer. In the past, there were many cases of acute pancreatitis or abdominal injury. The tumor was located in the upper abdomen. Left, palpation can be found that the tumor is round or oval, the boundary is unclear, sometimes the capsule is sexy, inactive, may be accompanied by symptoms of peripheral organs such as poor appetite and vomiting, ultrasound examination shows liquid level, X-ray examination showed that there may be calcified plaque in the pancreas. The barium meal examination is helpful for the diagnosis of this disease. It can be found that the stomach is pressed and moved forward, the duodenum is enlarged and the transverse colon is displaced upwards or downwards.
5. Pancreatic body tail cancer: The disease is characterized by abdominal pain, abdominal pain is located in the upper abdomen, and radiated to the lower back, chest, shoulder and rib margin, mostly for persistent dull pain and can not be alleviated, especially when lying on the back, especially at night Heavy, often forcing patients to bend down or bend over to the side, often accompanied by loss of appetite, diarrhea, weight loss and urine sugar positive, the upper abdomen or left upper abdomen touched the tumor mostly for late performance, retrograde gallbladder, pancreatic ductography, CT is helpful in the diagnosis of this disease.
6. Colon cancer: This disease is mainly characterized by changes in stool traits and bowel habits. It is not difficult to diagnose, but a small number of patients often see a diagnosis of abdominal mass, when ascending colon or descending colon cancer or hepatic flexion and splenic colon cancer invade surrounding tissues. The tumor is relatively fixed. If there is no change in stool characteristics and bowel habits in the medical history, barium enema examination or fiber colonoscopy should be performed. Tissue specimens can be collected for pathological examination. In addition, a small number of patients have no history of blood in the stool, but the fecal occult blood test is more. Those who are positive for the second time should also consider the possibility of this disease. The above special examination methods should be carried out to avoid misdiagnosis.
7. Tuberculous peritonitis: The disease may sometimes touch the tumor in the abdomen, and sometimes it is confused with the posterior wall of the abdomen, the intestine and the mesentery, and is easily confused with the retroperitoneal tumor. However, this disease is more common in young women and has chronic tuberculosis.;
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