Surgical Treatment of Huge Primary Retroperitoneal Tumor: A Report of 14 Cases

Zheng-jun Cheng, Qian Cheng, Jian-ping Gong, Chan Qiu, Da-xing Li

American Journal of Cancer Prevention

Surgical Treatment of Huge Primary Retroperitoneal Tumor: A Report of 14 Cases

Zheng-jun Cheng1, Qian Cheng2, Jian-ping Gong2, Chan Qiu3, Da-xing Li1,

1Department of General Surgery, The Second People's Hospital of Jiulongpo District, Chong Qing, China

2Department of Hepatobiliary, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China

3Department of Gastroenterology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China

Abstract

Objective: To summarize the surgical therapy for huge retroperitoneal tumor. Methods: Retrospective analysis was carried out to study the surgical therapy on 14 patients with huge retroperitoneal tumor. Results: Complete resection in eight cases, partial resection in two cases, combined evisceration in three cases, one biopsy and six cases recurred after surgery. Conclusion: Operative skills and the management during perioperative period are important for the treatment of huge retroperitoneal tumor.

Cite this article:

  • Zheng-jun Cheng, Qian Cheng, Jian-ping Gong, Chan Qiu, Da-xing Li. Surgical Treatment of Huge Primary Retroperitoneal Tumor: A Report of 14 Cases. American Journal of Cancer Prevention. Vol. 4, No. 4, 2016, pp 64-69. http://pubs.sciepub.com/ajcp/4/4/4
  • Cheng, Zheng-jun, et al. "Surgical Treatment of Huge Primary Retroperitoneal Tumor: A Report of 14 Cases." American Journal of Cancer Prevention 4.4 (2016): 64-69.
  • Cheng, Z. , Cheng, Q. , Gong, J. , Qiu, C. , & Li, D. (2016). Surgical Treatment of Huge Primary Retroperitoneal Tumor: A Report of 14 Cases. American Journal of Cancer Prevention, 4(4), 64-69.
  • Cheng, Zheng-jun, Qian Cheng, Jian-ping Gong, Chan Qiu, and Da-xing Li. "Surgical Treatment of Huge Primary Retroperitoneal Tumor: A Report of 14 Cases." American Journal of Cancer Prevention 4, no. 4 (2016): 64-69.

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At a glance: Figures

1. Introduction

Primary retroperitoneal tumor (PRT) refers to tumors stem from fat, muscle, lymphoid tissue, vessel or nerve tissue growing in retroperitoneal space. PRT is a kind of rare neoplasm without pathognomonic symptom and difficult to diagnose at early stages. The majority of PRT tend to be expansive, few of which can even grow up to tens of centimeters. Nonspecific symptoms may appear only when tumors expand to oppress or invade adjacent organs/structures [1]. Huge primary retroperitoneal tumors (HPRT, diameter ≥10cm) are much more rarely encountered on clinic. Surgical treatment as the optimal choice for HPRT has no regular surgical method to follow, and usually confronts serve challenges when involving vital organs. We report a series of cases of HPRT which were confirmed by surgical intervention and histopathological diagnose, and intend to share our clinical experience.

2. Materials and Methods

Fourteen patients with HPRT at our hospital received operations after diagnosis between January 2009 and October 2014 (Table 1). The group was composed of five males and nine females, mean age was 39.8 years (range 7-61 years). The mean diameter of tumors was 22.3cm (range 16-41cm, Figure 1 & Figure 2). Symptoms included abdominal mass (10 of 14), abdominalgia and/or abdominal distension (7 of 14), low back pain (3 of 14), urinary symptoms like dysuria or frequent urination (2 of 14) and progressive weight loss (1 of 14). In addition, tumors were found incidentally in three patients without uncomfortable symptoms. All patients underwent computerized tomography scans (CT) and/or magnetic resonance imaging (MRI), and other auxiliary examinations included ultrasound (9 of 14), gastrointestinal barium meal (GBM, 3 of 14), and intravenous pyelography (IVP, 2 of 14). Laboratory tests included tumor makers, blood routine examination, hepatorenal function, etc.

Table 1. The Information of Patients with HPRT

Figure 1. This picture shows the surgery procedure of patient No.3, and surgeons was pulling out most part of the tumor
Figure 2. The picture shows the tumor of patient No.3, and the diameter of it was 29cm

All the patients got exploratory laparotomy after diagnosis (Figure 1 & Figure 2). Operative incision differed depending upon the size of HPRT and where it lay in. Surgical procedures differed according to differential conditions, dividing into completely resection, partial excision, combined multiple organs resection and surgical biopsy.

3. Results

Five benign tumors and three malignant tumors were completely resected (57.1%). Two malignant tumors were sub-totally removed (14.2%). Combined multiple organs resection was performed in three cases (21.4%), two of them were tumorectomy accompanying with nephrectomy, the rest one was partial pancreatectomy, splenectomy and gastrectomy. One patient lost the opportunity of radical surgery, discharged after exploratory laparotomy and biopsy.

The histologic types of malignant tumor in this group consisted of malignant mesenchymoma (1), liposarcoma (4), hemangioendothelioma (1), and malignant mixed tumor (1); benign tumors were comprised of mesenchymoma (1), benign teratoma (2), angioleiomyolipoma (1), lipoma (2), and ganglioneuroma (1).

Intraoperative blood loss ranged from 50ml to 2,400ml, and 400-2,000ml blood was transfused into five patients during surgeries. Two patients were taken into ICU after surgery because of excessive bleeding, and were returned to ordinary wards after two or three days systemic treatments such as blood transfusion, anti-infection and nutritional support. There was no operative mortality and severe perioperative complications in these cases. The length of stay was from 8 to 20 days with an average of 12.1 days.

12 patients were followed up for 2 to 27 months, and six of them have been through recurrence, the mean interval of recurrence was 10.2 months (2-19 months). Four patients with benign tumor received reoperation once or twice and the patients with teratoma, hemangioendothelioma and angioleiomyolipoma haven’t experience recurrence yet, these seven patients were still alive; the patient with malignant mesenchymoma died 14 months later after reoperation; a patient with liposarcoma died without surgical treatment when tumor recurrence occurred; two patients with liposarcoma and one with malignant mixed tumor died 2-9 months later after discharged.

4. Discussion

PRTs are a class of neoplasm with multifarious pathological patterns and it’s hard to detect early and cure thoroughly. Adjuvant therapy like chemoradiotherapy has an uncertain status in the treatment for most types of PRT, and may be unable to improve the prospects of survival or reduce relapse rate [2, 3]. Some researchers suggest that synthetic therapy including surgery, chemotherapy, radiation and many other methods is well worth of further study [4]. However, surgery is still proved to be the most optimal choice for PRT by many literatures [3, 5, 6]. Sometimes preoperative radiotherapy even enhances surgical difficulty. As is reported, aggressive surgery relates tightly with long-term survival [7, 8], especially for malignant retroperitoneal tumors, but it’s still debatable about its effect on postoperative recidivation [9]. In this report, six patients with completely resection.

4.1. Preoperative Preparation

Adequate preoperative preparation is of much importance for HPRT surgery. After confirmed diagnosis by ultrasound, CT or MRI, examinations such as GBM, IVP, digital subtraction angiography (DSA), CTA and magnetic resonance angiography (MRA) can show organs/structures adjacent to HPRTs as well as the trend and distribution of vessels inside or around tumors. Surgeons assess the resectability of HPRTs, design reasonable operation methods and estimate the complexity of surgery with assistance from these examinations, which may enhance the success rate of surgeries. In a patient with mesenchymoma, CTA showed stomach and pancreatic had no clear boundaries with the HPRT, and branches of celiac axis, splenic artery and superior mesenteric vein contributed to the blood supply for tumor (Figure 3 - Figure 5). As corresponded to preoperative prediction, pancreatic body and tail, partial stomach and spleen were resected together with HPRT, and finally no related complications happened. In another two cases, preoperative IVP showed tumors had invaded kidney and upper ureter, as was confirmed in surgery, the kidney and upper ureter were wrapped and infiltrated by HPRT.

Figure 3. The picture shows the contrast-enhanced CT scan of patient No.1. The tumor pointed by double sided arrow squeezed adjacent organs. There’s no clear limit between stomach, the body and tail of pancreas and tumor
Figure 4. The pictures show the CTA scan of patient No.1. In the picture, celiac axis (red arrow), splenic artery (blue arrow) and superior mesenteric vein(red circle) contributed to the blood supply of the tumor, and vasoganglion formed
Figure 5. The pictures show the CTA scan of patient No.1. In the picture, celiac axis (red arrow), splenic artery (blue arrow) and superior mesenteric vein (red circle) contributed to the blood supply of the tumor, and vasoganglion formed

Patients with PRT usually suffer from weight loss, anemia, hypoproteinemia or poor nutritional status. Patients with malnutrition requiring surgical treatment should be supported by albumin, protein and glucose until hypoproteinemia was remedied and nutriture was ameliorated. Routine preparation of blood (1000-2000ml) before surgery was demanded, and it will be advisable to keep instruments for vascular surgery and vascular prostheses at hand in case of major vascular damage. Stomach tube, bowel preparation, ureteral catheterization and other preparations may be conducive to avoid intraoperative side injury in cases that PRT aggresses gastrointestinal tract or urinary system.

Just as importantly, once an operation is about to be performed, departments of anesthesiology, general surgery, urinary surgery and medical imaging require mutual cooperation. It may as well seek assistance from departments of Urology, Vascular Surgery or Gastrointestinal Surgery when facing something challengeable during surgery.

4.2. Surgical Procedure

Choosing appropriate surgical incision and acquiring good exposure is particularly indispensable due to HPRT’s large volume. Median abdominal incision, inverted T shaped incision or even waist incision can be selected for better operation field, fewer operational difficulty and accidental injury.

Achieving complete resection of HPRT is the gist purpose. The complete resection rate for PRT has been reported to be 38%-73% in some literatures [1], while in this group, 57% of the tumors (8 of 14) were completely excised. Inspecting and detaching HPRT accounts for the most part of surgery. Patients with good operative tolerance, circumscribed scope of tumor infiltration are more likely to achieve complete resection. Complete resection of HPRT depends mainly on the protection of vessels from vital organs and branches of aorta or postcava. The most common reason of incompletely resection is that vessels surrounded or adhered to HPRT are hard to avoid damage when dissecting. For completely resectable HPRTs, it makes sense to excise, repair and reconstruct injured vessels by experienced and skillful surgeons. The two incompletely resection HPRTs in this report tightly adhered to aorta and were hard to strip, so we had to resect part of these tumors.

If the tumor is found difficult to detach clearly from vital vessels, it has to leave part of it behind for partial resection in most cases. When exploring, keeping tumor capsule intact and avoiding residual tumors may lessen tumor metastasis and recurrence [10]. HPRTs with quite large size, tight adhesion or complicated anatomy of its fundus is sometimes permitted to resect part by part, which may cause intractable metastasis on the other hand. And then residual tumors need to be removed completely. While dealing with serious adhesion, sharp dissection shall be better for its less mechanical damage, in addition, it will be easier to start from superficial and loose places to dissociate tumors.

When major organs are encroached, or in situations that tumors can’t be fully separated without any damage to them, rashly excising may be inexpedient. Forcing to detach tumor from abdominal adhesion can lead to unmanageable hemorrhage, abdominal contamination and severer damage. So palliative resection or combined evisceration shall be taken into account. Among three cases of combined evisceration in this report, two patients’ invaded kidney was removed with the purpose of complete resection. The rest one’s spleen, part of pancreas and stomach were invaded, which was foreseen by CT and GBM.

Feeding vessels of huge tumors generally tend to be abundant, therefore, meticulous hemostasis is the difficulty and emphasis of this surgery. If hemorrhoea from unknown position occurs while detaching tissues, it’s preferable to use dry gauze pad to control bleeding than hemostatic forceps and find out bleeding site at once. If major vessels rupture, instruments for vascular anastomosis or repair are needed. Sometimes bleeding sites are covered by the huge tumor, it’s better to peel the tumor by blunt dissection as soon as possible, and transfuse blood, crystalloid and colloidal solution to supplement blood capacity immediately. Pack dry gauze on tumor bed when taking out the tumor. Remove gauze gently after several minutes’ oppression, and then ligature or suture bleeding spots and repair damaged blood vessels. A long-term operation for HPRTs and massive blood loss will do worse on coagulation function, and ligature, suture or even hemostatic material may be ineffective on controlling hemorrhage at that time. When bleeding is hard to stop in surgery, tamping several gauzes into bleeding tumor bed in sequence, leaving one corner outside of body and then pull out one gauze each day. As was observed, packing hemostasis of gauze compression is convenient and efficient. The hemorrhage of the patient whose intraoperative blood loss of 2,400ml was stopped by this method. Fluids like blood, pus or urine may be extracted when puncturing some HPRTs, which will probably shrink they volume and reduce the operating difficulty.

Operators should bear in mind that cautious dissection especially on major vessels is the key of preventing severe intraoperative injuries and avoiding blood circulatory disturbance or other related complications. If surgeon has confidence to accomplish complete resection and is forced to operate on major vessels, preparing vascular surgery instruments and consulting vascular surgeon immediately are imperative.

4.3. Postoperative Management

Postoperative management is also a vital component of HPRT surgery. The physiological indicators should be monitored frequently and serve as the major gist to adjust treatment plan, vital signs, abdominal drainage or urine volume should be also pay close attention to. HPRT occupies a lot space of abdominal cavity, so the decrease of intra-abdominal pressure after tumor removal may trigger effective circulating blood volume deficiency or even hypovolemic shock. So maintaining water, electrolyte and acid base balance according to laboratory results holds an important position in foundational supportive treatment after surgery. And parenteral nutrition (PN) is usually indispensable for resuming in a short period after operation, especially for patients with tumors that involve stomach and intestines. If pancreas is involved, somatostatin or octreotide is utile for guarding against pancreatic leakage. Proton pump inhibitor, liver protectant and antibiotics also serve the purpose of reducing post-operative complications.

PRT, whether malignant or benign, has a tendency of recidivating. Linehan et al. found a positive correlation between the tumor size and local recurrence as well as metastasis rates [11]. Relapse rate was reported to be 72% and 91% in five and ten years, and in this report, six patients have experienced recidivation (6 of 12, 50%). Some factors bring about the relapse of HPRT, such as the tumor's biological characteristics, deficient resection scope and cancer cell exfoliation and implantation during surgery. There’s reason to believe that meticulous operation does much help to reduce postoperative recurrence. Regular follow-up is essential for patients underwent PRT surgeries. It’s recommended to recheck ultrasound, MRI or CT scanning every three months in the first two years after surgery and then examine once or twice a year. Surgery is still the first choice for recurrent HPRT [12].

4.4. Treatment for Tumors not to Operate

PRT is not sensitive to chemotherapy and radiation therapy, and needs to surgical treatment after diagnosis generally. However, the chemotherapy or radiation therapy is very necessary for the patients who lost the opportunity to operation, it can prolong the survival and promote the living quality of patients. For the patients with difficulty of complete tumor resection, should not importune completely removed, given chemotherapy postoperative can still obtain good curative effect, especially, the retroperitoneal malignant lymphoma. With the development of medical science, many other treatments for PRT are development such as biological immune and molecular target treatment. Those treatments unite with surgical treatment will bring hope for patients with PRT.

5. Conclusion

Since no other effective therapies for HPRT, continually improving and enhancing surgical technique is the main approach for the sake of fully resection of HPRTs and improved prospects of survival initiate. Aggressive multidisciplinary surgical treatment and sufficient preoperative preparation also act as important roles in the treatment of HPRT.

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