Two-dimensional pulsed echo detection of para-aortic lymph nodes.
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Eighty-five patients with locally advanced intra-abdominal, retroperitoneal, and pelvic malignant diseases have been treated at the National Cancer Institute (NCI) with electron beam intraoperative radiotherapy (IORT). In general, IORT was performed after resection to the tumor bed and to areas of locoregional spread. IORT was delivered directly to some unresectable tumors. The median survival for the entire NCI patient group was 13.9 months, with 34% of the patients projected to achieve local control of disease at 5 years. Multiple abutting IORT fields were used in 76% of the patients; they encompassed treatment areas as large as 569 cm2 and involved as many as five separate IORT applications. Multiple fields were matched along straight edges on the treatment applicators or provided by means of lead shielding strips. Areas of field overlap were prevented by the use of lead shields. Surgical approaches and radiotherapeutic techniques of multiple field matching have been developed and are detailed for carcinoma of the pancreas, carcinoma of the stomach, sarcomas of the retroperitoneum, carcinoma of the rectum, and tumors of the pelvic girdle.
Five rare retroperitoneal fibrohistiocytic tumors of children are described mainly in reference to the pathological aspects. A more detailed description is given of a retroperitoneal xanthogranuloma, including an ultrastructural study. This case is particularly interesting for its rapid transformation into a fibroxanthosarcoma. The other cases include two fibroxanthosarcomas, a storiform fibrous xanthoma, and a malignant histiocytoma. The most difficult points in the recognition and in the differential diagnosis of these tumors are discussed, and emphasis is placed on some interesting pathological features. Prognosis of such tumors appears difficult to assess from our series since two patients died in the immediate postoperative period, one died one and a half years after the discovery of the tumor, and two are alive and well, but with a short follow-up.
The magnetic resonance (MR) imaging features of liposarcoma were correlated with histology in 15 patients. The MR findings for liposarcoma were not specific. The six myxoid liposarcomas and two atypical lipomatous tumors, however, had distinctive MR features, i.e., nodular masses of slightly heterogeneous intermediate to high signal intensity (SI), intermingled with high SI septa on T1-weighted images. The T2-weighted images demonstrated the relative reversal of these regional SI characteristics. Additionally, MR correctly identified the presence of fat in all eight cases in which it was pathologically present. The fat in two atypical lipomatous tumors was inseparable on MR from the subcutaneous fat. Magnetic resonance appears useful for preoperative staging and follow-up studies of liposarcomas. It may be helpful in identifying patients with myxoid liposarcoma and atypical lipomatous tumors who have longer survival times.
The value of CT and lymphography of the retroperitoneum was compared in 31 patients with testicular tumors. In no patient with normal or equivocal lymphography was more information gained by CT. In abnormal cases, the presence of metastatic deposits was well detected at both examinations, but CT proved more useful in defining the exact extent of the tumor and facilitated the proper arrangement of the irradiation fields. A strategy in the sequence of investigation in testicular tumors is suggested, aiming to save CT time when CT information is not likely to be of significance for treatment planning.
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Computed tomography (CT) was performed on four patients in whom excretory urograms revealed marked displacement of the kidneys and/or ureters. CT in each case was remarkable for the presence of excessive accumulation of normal retroperitoneal fat and failed to document the existence of a retroperitoneal neoplasm, lymphadenopathy, or other pathological mass.
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Retroperitoneal fibrosis, an uncommon and ill-defined condition, has a variety of causes and presenting features. The fibrotic process often produces ureteral obstruction and compression of surrounding structures. Pain in the flank, lower abdomen or lumbosacral region is the most common presenting symptom. Certain drugs, neoplasms, retroperitoneal injury or infections may all initiate the fibrotic process. This article describes a case of retroperitoneal fibrosis in a 34-year-old man who had been receiving a beta-adrenergic blocking agent.
The operative treatment of chronic contained rupture of a saccular abdominal aortic aneurysm (AAA) with retroperitoneal haematoma is reported. A 62-year-old man presented with a painless abdominal mass and intermittent claudication. He had an episode of severe abdominal pain about 2 years before admission. A giant retroperitoneal neoplasm was initially suspected, based on computed tomography. However, magnetic resonance imaging, angiography and colour Doppler sonography demonstrated chronic contained rupture of an AAA. A punched-out oval defect (width 3.5 cm x length 4.5 cm) that was thought to connect the thrombosed aneurysm to an organized retroperitoneal haematoma was discovered in the posterior wall of the bifurcation of the aorta at laparotomy. An infrarenal aortobiexternal iliac Y-graft with bypass to the left femoral artery was placed without removing the aneurysm or haematoma. Recovery was uneventful. The retroperitoneal haematoma appeared smaller on computed tomography about 1 year after operation. This case fulfilled the criteria for chronic contained rupture of an AAA proposed by Jones and associates.
In a study of the sympathetic trunk in 18 cadavers a new anatomical approach for modified bilateral retroperitoneal lymphadenectomy was developed, which is characterized by unilateral preservation of the L3 ganglion and the fibers arising from this ganglion. Furthermore, the sympathetic trunk and its lumbar branches were dissected, including the connections between the right and left sympathetic trunks arising from the L3 and L4 ganglia. On the right side the fibers were found dorsal to the inferior vena cava from where they pass into the aortocaval zone. Caudal to the inferior mesenteric artery these fibers communicate with the left para-aortic fibers. The precise topographic inter-relationship between the L2 and L3 ganglia was studied; the lower margin of the L3 ganglion was located 1 cm. cranial to the origin of the inferior mesenteric artery. Based on these findings a modified operative technique was developed for stages B1 and B2 testicular tumors. With the help of this modification it should be possible to preserve ejaculatory function in 50% of the patients who undergo an operation for small retroperitoneal tumors. However, this modification can be justified only if the recurrence rate is not higher than that with radical bilateral lymphadenectomy.
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Two cases of retroperitoneal edema surrounding the left ovarian vein that were associated with large uterine leiomyoma are presented. This finding was not associated with any specific lateralizing symptoms or with any evidence of malignancy. One patient underwent hysterectomy with surgical exploration of the retroperitoneum that confirmed the absence of malignancy. The CT and MR findings in this entity are described and possible etiological mechanisms discussed. Recognition that large leiomyoma can be associated with benign retroperitoneal edema may help avoid inappropriate management.