Eur Radiol 2006 ;16:2652–2660. Disease of the Peritoneum and Retroperitoneum Cody Starnes. 26, No. Extragonadal germ cell tumor is often seen in or near the midline, especially between the T6 and S2 vertebrae. NHL is the most common cause of lymphadenopathy. Viewer. Mesenteric fibromatosis - Desmoid (3) At CT, synovial cell sarcoma is hypoattenuating, with peripheral irregular enhancement and central areas of necrosis. Notice that this lesion is not of low attenuation. CT images show an ill- or well-defined mass with relatively high attenuation (Fig 10). Fat-containing lesions of the retroperitoneum: radiologic-pathologic correlation, Leiomyosarcoma of the retroperitoneum and inferior vena cava: radiologic-pathologic correlation, Imaging primary and secondary tumor thrombus of the inferior vena cava: multi-detector computed tomography and magnetic resonance imaging, Imaging and clinical spectrum of rhabdomyosarcoma in children, Imaging of primary chondrosarcoma: radiologic-pathologic correlation, Primary retroperitoneal extraskeletal mesenchymal chondrosarcoma: a computed tomography diagnosis. CT or MR imaging shows a mass lesion with areas of calcification, necrosis, and heterogeneous enhancement (Fig 6). Korean journal of radiology. On T2 there is relatively high signal. 37, No. On the left images of a male patient, who presented with a lower abdominal mass. The mass is displacing the IVC.Figure 33Download as PowerPointOpen in Image Approximately 14% of the patients with non-Hodgkin lymphoma present with a retroperitoneal mass. This tumor is also one of the primary peritoneal malignancies. Xray film & film processing Rakesh Ca. 47, No. Desmoid tumor is hormonally responsive and dependent on estrogen. 1, 1 October 2020 | RadioGraphics, Vol. 9, No. Figure 21 Posttransplant lymphoproliferative disease in a 59-year-old man with a history of liver transplantation. Axial contrast-enhanced CT image obtained at the level of the L5 vertebra shows a large mass with areas of necrosis in the right posterior pararenal and paravertebral spaces. Pseudomyxoma peritonei is often confused with mucinous carcinomatosis. 27, No. Chondrosarcoma is a malignant tumor that produces cartilage matrix. 11.1 Transabdominal ultrasound of cystic abdominal mass demonstrating an anechoic, irregularly shaped cystic lesion at midline located anterior to the SMA and SMV and inferior to the pancreas. 2, 15 January 2015 | RadioGraphics, Vol. At CT and MR imaging, neuroblastoma is irregular, lobulated, and heterogeneous and demonstrates coarse amorphous calcifications and variable contrast enhancement, as well as invasion of adjacent organs and encasement of vessels with luminal compression. 27, No. In a male patient this is a very uncommon diagnosis. The histopathologic findings from biopsy showed schwannoma.Figure 11Download as PowerPointOpen in Image Recognize the imaging features of various retroperitoneal masses. Figure 5 Malignant fibrous histiocytoma in a 49-year-old woman. Malignant Nerve Sheath Tumor.—Malignant nerve sheath tumors include malignant schwannoma, neurogenic sarcoma, and neurofibrosarcoma. 3, Journal of Gastrointestinal Cancer, Vol. The diagnosis is made only after excluding multiple myeloma in the bone marrow or any bone lesion by using a skeletal survey or bone marrow MR imaging, with normal results of plasma electrophoresis. This tumor is histologically identical to malignant ovarian surface epithelial tumors. Axial contrast-enhanced CT image shows a large lobulated irregular homogeneous mass (straight arrows) that is encasing and anteriorly displacing the abdominal aorta (curved arrow). Serous cystadenocarcinoma is seen in women with normal ovaries. The prognosis is good after surgical resection of a ganglioneuroma (28).Figure 15 Ganglioneuroma in a 31-year-old man. Primary Retroperitoneal Neoplasms: CT and MR Imaging Findings with Anatomic and Pathologic Diagnostic Clues. The soft tissue mass is usually dark on T1W and T2W unless there is an active inflammation whereby the T2W images can be hyperintense. Variable signal intensity is seen on T2-weighted images. Crossref , Medline , Google Scholar Axial contrast-enhanced CT image shows a large cystic mass (arrow), with solid papillary fronds (arrowhead) within it. 3, No. After contrast enhancement, schwannoma demonstrates variable homogeneous or heterogeneous enhancement (28). In peritoneal carcinomatosis we see tumor nodules along the peritoneal lining (arrow), omental tumor deposits, and bowel obstruction. Artefacts mr & ct Rakesh Ca. The mass is displacing the IVC. This finding is only rarely seen. Nonpancreatic pseudocyst is usually asymptomatic, without elevation of serum amylase or lipase levels. A heterogeneous mass containing fat could be a dedifferentiated liposarcoma, myelolipoma, or angiomyolipoma. Other solitary solid tumors like ... can have the same presentation. A pure fat-containing mass implies either a lipoma or a well-differentiated liposarcoma. Ten to fifteen percent of liposarcomas occur in the retroperitoneum, and they are more common in the 50–70-year age group, with no sex predilection (1). Histopathologically, myelolipoma is well encapsulated, and it has myeloid and erythroid precursors, with mature adipose tissue and occasionally hemorrhage and calcification (22). The posterior pararenal space (PPRS) is located between the posterior renal fascia (PRF) and the transversalis fascia (TF). 7, The Korean Journal of Helicobacter and Upper Gastrointestinal Research, Vol. Fibrosis has low signal intensity on T2-weighted MR images, with minimal enhancement. Coronal contrast-enhanced T1-weighted fat-suppressed gradient-echo MR image shows that the IVC is expanded by a large intraluminal mass that shows heterogeneous enhancement (arrow). Retroperitoneal cystic masses, which arise within the retroperitoneal space but outside the major organs within that compartment, are uncommon. It occurs in premenopausal women with prior gynaecological surgery or infection that results in peritoneal scarring. 2, 13 March 2017 | RadioGraphics, Vol. Notice the retraction of the bowel and also notice the resemblance to carcinoid. Magnetic Resonance Imaging (MRI) for Retroperitoneal Mass or Tumor; Provides information of vascular structures close to tumor; Cystic tumor mass; Necrotic tumor mass; Enhancing tumor compressing surrounding soft tissue. A well-defined cystic lesion is seen in the retroperitoneum, more commonly in the perirenal space. 2, 3 January 2017 | Insights into Imaging, Vol. Finally, diagnostic clues for retroperitoneal masses are reviewed. Note also the mass (arrowhead) in the posterior pararenal space, posterior to the right kidney. Mature teratomas are predominantly cystic. Viewer. Usually there are other sites with lymphoma. Axial contrast-enhanced CT image shows a well-defined enhancing rind of soft tissue (arrow) surrounding the abdominal aorta. Cystic degeneration is rare. Cystic retroperitoneal masses are presented next, grouped into cystic neoplastic masses and cystic nonneoplastic masses. Most (80%) of these cases are associated with Epstein-Barr virus infection, and the manifestations range from benign infectious mononucleosis to non-Hodgkin lymphomas. Retroperitoneal mass Kundan Singh. This form is mostly named panniculitis mesenterialis. 8, No. Tailgut cyst originates from embryonic hindgut remnants. Histopathologically, lipomatosis is composed of homogeneous, mature, adult white fat cells separated by fibrous septa. Usually there are omental metastases, i.e. Lymphangioleiomyoma is the third most common (16%–21% of these patients) abdominal manifestation of lymphangioleiomyomatosis (57,58), after angiomyolipoma (70% of patients) and enlarged lymph nodes (57). 3, 10 June 2015 | Current Radiology Reports, Vol. The hormonally active ovaries secrete fluid that becomes loculated in the pelvis. 78, No. Viewer The first step when diagnosing peritoneal or mesenteric masses is to separate them into cystic and solid. Approximately 6% of leiomyosarcomas arise from the IVC (1). 274, No. Malignant transformation is rare (3,28,29).Figure 11 Schwannoma in a 41-year-old woman. Viewer. Liposarcomas are less well defined, are unencapsulated, and are infiltrative without hemorrhage, compared with myelolipomas. The tumor can be asympto-matic or can manifest with hemorrhage. Primary retroperitoneal masses include a diverse, and often rare, group of neoplastic and non-neoplastic entities that arise within the retroperitoneum but do not originate from any retroperitoneal organ. It is the result of chronic inflammation with an unclear pathogenesis. Neurofibroma.—Neurofibroma is a benign nerve sheath tumor that can occur as an isolated tumor (90%) or as part of type 1 neurofibromatosis. Teratoma.—Teratoma is a germ cell tumor that originates from pluripotent germ cells that have been interrupted in their normal migration to the genital ridges. Extraskeletal lesions are seen in 50% of cases of Erdheim-Chester disease, with retroperitoneal involvement seen in one-third (45). 5, International Journal of Gynecological Cancer, Vol. Occasionally the primary gonadal tumor might not be visible because tumor regression has left only a scar, with synchronous or asynchronous metastasis. CT shows a well-defined fluid collection (Fig 34a), with progressively increasing attenuation caused by contrast-enhanced urine entering the urinoma (Fig 34b). Enlarged vessels coursing through the lesion (Fig 8), aneurysms, and associated hemorrhage are features that enable distinguishing an angiomyolipoma from liposarcoma (12). Calcification (toothlike or well defined) and fat can be seen in 56% and 93% of cases, respectively (37) (Fig 18). 2, © 2021 Radiological Society of North America, CT characteristics of primary retroperitoneal neoplasms, Primary retroperitoneal neoplasms: CT and MR imaging findings with anatomic and pathologic diagnostic clues, MR imaging of soft-tissue masses of the extraperitoneal spaces, Gerota versus Zuckerkandl: the renal fascia revisited, CT of the extraperitoneal space: normal anatomy and fluid collections, CT and MR imaging of extrahepatic fatty masses of the abdomen and pelvis: techniques, diagnosis, differential diagnosis, and pitfalls, Retroperitoneal liposarcoma: MR characteristics and pathological correlative analysis. Imaging findings are nonspecific, but this tumor should be considered in the differential diagnosis when a young patient presents with a retroperitoneal mass. CT shows a large thin-walled unilocular or multilocular cystic mass (Fig 28) with attenuation values ranging from that of fat (caused by chyle) to that of fluid. Perivascular Epithelioid Cell Tumor.—Perivascular epithelioid cell tumor (also called PEComa) is a mesenchymal tumor that is composed of distinctively perivascular epithelioid cells, which are radially arranged cells around a vascular lumen. 157, No. Calcification is seen in as many as 30% of cases and is an important sign of dedifferentiation. Neuroblastoma is malignant and is more commonly seen in males and in the 1st decade of life. Calcification is rarely seen. The FDG PET scan shows increased uptake of FDG and is useful for detecting metabolic activity and distant disease (45). Viewer. 33, No. Axial CT image shows a large heterogeneous mass with areas of curvilinear calcification (arrow) in the retroperitoneum. Viewer So these are the things to look for. The imaging findings are nonspecific. The anterior pararenal space (APRS) is located between the parietal peritoneum (PP) and the anterior renal fascia (ARF) and contains the pancreas (Pan), the ascending colon (AC), and the descending colon (DC). This feature is highly suggestive of leiomyosarcoma.Figure 4Download as PowerPointOpen in Image Soft tissue masses with “cyst-like” appearance on MR imaging: distinction of benign and malignant lesions. The clinical spectrum ranges from asymptomatic bone lesions to systemic illness and death. Vascular tumors such as paragangliomas and hemangiopericytomas demonstrate flow voids on spin-echo T1-weighted MR images, hemorrhagic necrosis with fluid-fluid levels, and intense contrast enhancement. … The recurrence rates are high, and metastases to liver, lung, bones, and brain may be seen (1,2). Lymphoma.—Lymphoma is the most common retroperitoneal malignancy, accounting for 33% of all of these cases (1). The duodenum, IVC, and aorta have been displaced by the tumor. Figure 29 Lymphangiomatosis in a 26-year-old man. Most lymphangiomas are located in the neck, but 5% of lymphangiomas are abdominal. Although the differential diagnosis of retroperitoneal masses can be narrowed down to a certain extent on the basis of imaging characteristics, patterns of involvement, and demographics, there is still a considerable overlap of imaging findings for these masses, and histologic examination is often required for definitive diagnosis. At MR imaging, the septa are hypointense on T2-weighted images and show contrast enhancement. These methods enable determination of retroperitoneal … First study the images on the left and continue with the MR. Viewer. 6, 18 September 2017 | Journal of Feline Medicine and Surgery Open Reports, Vol. Axial CT image shows a large mass containing fat (arrow) and soft-tissue (arrowhead) components in the right side of the retroperitoneum. Miscellaneous Uncommon Neoplasms.—Chordoma is a tumor that arises from notochordal remnants and is seen most commonly in the sacrococcygeal region as a heterogeneously enhancing soft-tissue mass, with bone destruction of the sacrum and involvement of adjacent organs. Furthermore, lipoma is less common than liposarcoma in the retroperitoneum (9,11,12). Hodgkin lymphoma has a bimodal age distribution, occurring in patients in their 20s and 60s, and manifests with limited disease, often involving the mediastinum and spleen. Axial CT image of the abdomen shows that a nonspecific well-defined unilocular simple cyst (arrow) in the right retroperitoneal space is displacing the colon anteriorly. Coronal CT image obtained after the biopsy shows a heterogeneous predominantly cystic-appearing hematoma (arrow) in the right retroperitoneal space. 45, No. Based on the history this was suspected to be a metastasis. The clinical features enable differentiation from other cystic neoplasms (56). Tumors involving the superior segment of the IVC (above the hepatic veins) may manifest with Budd-Chiari syndrome, those of the middle segment (between the hepatic and renal veins) manifest with right upper quadrant pain or tenderness or the nephrotic syndrome, and tumors of the inferior segment (below the renal veins) manifest with pain and lower extremity edema (13). Now accompanying that J-pouch is mesentery in which mesenteric fibromatosis has developed. CT and MR imaging show a unilocular thin-walled cyst in the presacral space (56). Histopathologically, neurofibroma is an unencapsulated solid tumor that (a) is composed of nerve sheath cells and collagen bundles with variable myxoid degeneration and (b) causes expansion of the entire nerve, with nerve fibers traversing the tumor. Figure 8 Perivascular epithelioid cell tumor (also called PEComa) in a 38-year-old man. At this stage it is no different upon imaging to other tumors, however, the age of the patient provides the clue to the diagnosis. 6, 12 September 2017 | RadioGraphics, Vol. Ganglioneuroma occasionally secretes hormones such as catecholamines, vasoactive intestinal peptides, or androgenic hormones (30). Rarely, paraganglioma can manifest with acute abdomen caused by retroperitoneal hemorrhage. Ultrasound of the Neonatal spine; Unsorted. At CT, neurofibroma is depicted as a well-defined round homogeneously hypoattenuating lesion (20–25 HU) because of the presence of lipid-rich Schwann cells and adipocytes and entrapment of adjacent fat (Fig 12). Figure 19 Granulosa cell tumor in a 44-year-old woman. Most of the retroperitoneal neoplasms are of mesodermal origin, with liposarcomas, leiomyosarcomas, and malignant fibrous histiocytomas making up more than 80% of these tumors. A poor prognosis is associated with lesions with germ cells or lesions with rhabdomyosarcoma or neural differentiation. Retroperitoneal fibrosis may lead to ureteric obstruction and consequent renal failure. Diagnosis and Surveillance of Incidental Pancreatic Cystic Lesions: 2017 Consensus Recommendations of the Korean Society of Abdominal Radiology. (Images courtesy of Joel A. 6, 17 April 2020 | RadioGraphics, Vol. Secondly we have to realize that any loculated fluid collection due to infection, i.e. Surgical resection is required because of the risk of malignant degeneration, which manifests at CT with involvement of adjacent structures and loss of discrete margins. Retroperitoneal cysts should be differentiated from mesenteric, omental, splenic, and enteric duplication cysts. Stichting Radiology Assistant - ANBI; Information; Apps. CT Guided Biopsy-The study provides diagnosis of type of tumor and also if tumor is malignant or benign in character. Extraosseous plasmacytoma has a better prognosis than the solitary bone plasmacytoma. Notice the thickened falciform ligament. Figure 7 Angiosarcoma in a 61-year-old woman. Br J Radiol, Radiological findings of primary retroperitoneal synovial sarcoma, Primary retroperitoneal synovial sarcoma: a case report, Neoplasms of the perivascular epithelioid cell involving the abdomen and the pelvis: cross-sectional imaging findings, Extraadrenal myelolipoma: MR imaging findings, Retroperitoneal extraadrenal myelolipoma: technetium-99m sulfur colloid scintigraphy and CT imaging, Imaging of intra- and extraabdominal desmoid tumors. It is one of the most common primary retroperitoneal neoplasms. Myelolipoma is usually asymptomatic but can manifest with discomfort or pain caused by hemorrhage or compression. 1, 2 = cursors used to measure attenuation values.Figure 32Download as PowerPointOpen in Image Table 3 Imaging Features Suggestive of a Specific Diagnosis for Retroperitoneal Masses. Viewer. 6, 22 July 2015 | Iranian Journal of Radiology, Vol. Step 3-Retroperitoneal lesions from retroperitoneal … On the left a nice radiological pathological correlation. 41, No. The posterior pararenal space is situated between the posterior renal fascia (Zuckerkandl fascia) (5) and the transversalis fascia, whereas the perirenal space is located between the anterior renal fascia and the posterior renal fascia. Extramedullary hematopoiesis is characterized by abnormal deposits of hematopoietic tissue outside the bone marrow as a compensatory mechanism for reduced hematopoiesis by the bone marrow. At MR imaging, lymphangioma has low signal intensity on T1-weighted images and high signal intensity on T2-weighted images. This cyst proliferates with abnormal hormonal stimulation, such as in obese women with menstrual irregularities. 97, No. Variable patterns of calcification can be seen (7%–20% of cases) in the peripheral portions of these tumors. 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