MANAGEMENT OF A CASE OF RETRO PERITONEAL TUMOR.pptx

A case of Retroperitoneal tumor management

1. RETROPERITONEAL TUMOR DR NEHA GP DEPT OF GENERAL SURGERY (PG Y -3 ) KIMS & RC GUIDE – DR PRAVENKUMAR RR, SURGICAL ONCOLOGIST

2. PATIENT DETAILS Mrs. Govindammal , 56/F IPNo : 202506120101 UHID: 0306250409 ADMITTED FOR EVALUATION OF ABDOMINAL PAIN IN SURGICAL Unit - S3 EVALUATED AND MANAGED BY SURGERY-Surgical Oncology TEAM

3. HISTORY AND EXAMINATION Patient was apparently normal 1 month ago after which she complained of VAGUE lower abdomen pain , radiating to the back for the past one month ,not associated with SPECIFIC aggravating OR relieving factors No h/o nausea , vomiting , diarrhoea ,constipation ,bleeding per rectum , malena (UGI/LGI SYMPTOMS) No h/o urinary complaints , hematuria , reduced urine output , bilateral lower limb edema ( GU SYMPTOMS ) NO H/O BLEEDING PV, ABDOMINAL DISTENSION/SWELLING ( GYNEC SYMPTOMS) No h/o Fever, loss of weight, loss of appetite ( TB/MALIGNANCY/LYMPHOMA ) SYMPTOMS

4. EXAMINATION AND EVALUATION Examination: NORMAL GENERAL AND SYSTEMIC EXAMINATION INVESTIGATIONS: CBC/RFT/LFT – NORMAL USG ABDOMEN AND PELVIS : No significant abnormalitieS UGI Endoscopy: Normal study

5. WHAT NEXT ? MANY PIECES ARE MISSING IN THE JIG SAW PUZZLE

6. NON-SPECIFIC INVESTIGATION CECT - ABDOMEN AND PELVIS soft tissue density mass in retroperitoneal region with heterogeneous contrast enhancement and causing mass effect over aortic and Iliac vesselS likely a metastatic node OR lymphoma OR RETROPERITONEAL TUMOR

7. WHAT NEXT? SOME PIECES FOUND SPECIFIC INVESTIGATIONS FOR LYMPHOMA NODAL SECONDARIES RETROPERITONEAL TUMOR SYSTEMIC MALIGNANT OR INFLAMMATORY DISEASE TISSUE DIAGNOSIS

8. SPECIFIC INVESTIGATIONS Ct guided biopsy – NOT FEASIBLE due to the close location of the mass to major vessels PET-CT Whole body Scan Localised low-grade metabolically active retroperitoneal mass at L4-L5 level - ? Schwannoma/ neurofibroma ? myxoid liposarcoma ? lymphangioma. NO DISEASE ELSEWHERE

9. WHAT NEXT? ONLY MISSING PIECE TO SOLVE THE PUZZLE - SURGERY – LAPAROSCOPY FOLLOWED BY EXPLORATORY LAPAROTOMY AND PROCEED

10. LAPAROSCOPY FINDINGS AND PLAN supraumbIlical 10mm port and two 5mm ports. Retroperitoneal tumour found at L4-L5 level in the midline between aorta-IVC-common iliac vessels and vertebral bodies, pushing the vessels anteriorly Proceeded with midline laparotomy.

11. SURGICAL STEPS Peritoneal incision made along right line of Toldt & visceral rotation done from R to L to expose the retroperitoneum from L2 level to S1 level. Both ureters identified & lateralized. Exposure of aorta-IVC-bifurcation done. Proximal & distal vascular control obtained & vessels looped with vascular tapes. Tumour dissected off the vessel anteriorly & off the vertebral bodies posteriorly using sharp dissection. Specimen removed in toto. Hemostasis secured. Tumour bed cauterized. Wash given using 4L of warm saline

12. POST EXCISION

13. POSTOP PERIOD Patient had Tachycardia and hypotension (neurogenic) T.ivabrad 2.5mg stat T.midodrine 5mg TDS PERIOPERATIVE CARE BY TEAM OF ANESTHETISTS, ICU CONSULTANT, AND SURGICAL TEAM DISCHARGED ON POSTOP DAY 10 WITH NORMAL BP AND HAVING STOPPED ORAL IONOTROPIC AGENT.

14. HPE REPORT Chondrosarcoma grade 1, tumor size 6.5cm in greatest dimension, evidence of infiltration into surrounding fibrofatty tissue four reactive inter aorto- caval lymph nodes seen. PUZZLE SOLVED

15. WHAT COULD HAVE BEEN DONE? IT IS AN UNPLANNED R1 RESECTION INTRAOP FROZEN SECTION ALONG WITH EXCSION OF TUMOR, EXCISION OF PART OF VERTEBRAL BODY COULD HAVE BEEN DONE BASED ON FROZEN REPORT, THUS MAKING IT A PLANNED R1/R0 RESECTION

16. TUMOR BOARD DISCUSSION Being an R1 resection , Re-resection/excision is ideal . However, in view of increased morbidity and technically challenging resection which may not entail complete resection due to the axial location of tumor, Surgery can be deferred. Radiotherapy not advised due to less benefits in grade 1, R1 resection of chondrosarcoma. Advised strict compliance in follow up. Repeat imaging (MRI) to look for any gross residual disease at 1 month post op. 3 monthly imaging thereafter.

17. FOLLOW UP FOLLOW UP MRI ABDOMEN taken AFTER 1 MONTH Post operative changes with L4- L5 intervertebral disc space inflammatory changes , L4- L5 vertebral body marrow edema and small localized paravertebral collection at L4- L5. NO RESIDUE

18. TAKE HOME MESSAGE EVALUATION OF A VAGUE SYMPTOM HAS HEPLED US PICK A RETROPERITONEAL TUMOR KEEPING IN MIND THE DIFFERNETIAL DIAGNOSIS OF RETROPERITONEAL TUMORS, RELEVANT SPECIFIC INVESTIGATIONS WERE DONE CHALLENGING SURGERY – LASTED 7 HOURS WITH LESS THAN 500 ML BLOOD LOSS AND NO IATROGENIC VESSEL INJURY DESPITE THE AXIAL LOCATION OF TUMOR PREOP BIOPSY OR INTRAOP FROZEN IS IDEAL FOR COMPREHENSIVE ONCOLOGICAL MANAGEMENT IN SUCH CASES (NOT ALL RP TUMORS)

19. TEAM WORK SURGEON ANESTHETIST ICU CONSULTANT RADIOLOGIST NUCLEAR PHYSICIAN PATHOLOGIST TUMOR BOARD