Case Presentation of Retroperitoneal Mass. By : Dr. Khalid Jamal Hamdi. History. MRN:517400 (Hera Hospital) Saad is 43 y/o saudi male patient Presented to ER Main complaint: left lower quadrant pain x 2days associated with Lower back pain. History.
By : Dr. Khalid Jamal Hamdi
MRN:517400 (Hera Hospital)
Saad is 43 y/o saudi male patient
Presented to ER
left lower quadrant pain x 2days associated with
Lower back pain
relieved by NSAID.
The patient had a previous similar attacks during the last 6 months but he didn’t seek medical advise
No H/o : Dysuria ,nausea ,vomiting ,change in
Bowel habit, fever.
No H/o : trauma
other review of systems were unremarkable
Past M Hx: unremarkable.
Past surgical Hx: appendectomy 14 y ago.
Social Hx :Smoker 2 packs /day
married ,had 5 kids
Allergy: No non allergies to food or medication
BP:130/90 , T : 36.7
not in pain , No Jaundice or pallor
No cyanosis , ( PI: 2/10 )
Soft,lax , no tenderness , no organomegaly
No palpable mass
Audiable bowel sound
showshuge echogenic well defined homogenously solid mass (11.7x8.4 cm)
at retrovesical pouch (?? Colonic mass)
shows evidence of well defined soft tissue mass in the pelvic cavity about (10.5x8.5cm)
seen at the area behind the urinary bladder more to the left side at the level of rectosigmoid with pedicle toward the sacrum.
the mass displace the UB ant. and Compressing the area of rectosigmoid
No bony erosions
Other abdominal organs are normal
No free fluid
Finding intra operatively:
huge retroperitoneal mass approximately
adherent to Lt ureter ,Lt Iliac vessels,
Schwannomas ( neurilemomas).
are usually benign tumors arising from Schwann cells of the peripheral nerve sheath.
and belong to the category of
neural sheath tumors
schwannomas are benign, although malignant cases are known to occur,
especially when there is association with
Von Recklinghausen‘s disease,
rarely occur in the retroperitoneum, comprising 0.5% to 5% of all schwannomas.
Their usual location is the head, neck, the flexor surfaces of the extremities and the posterior mediastinum or the retroperitoneum
They can be found in any nerve trunk,
except for ?? ,
Bastounis E, Asimacopoulos PJ, Picoulis E, Leppaniemi AK, Aggouras
D, Papakonstandinou K, Papalambros E: Benign retroperitoneal
neural sheath tumors in patients without von Recklinghausen's
disease. Scand J Urol Nephrol
Except cranial nerves I and II
Diagnosis in the retroperitoneal position is difficult,
and a large and deeply situated tumor is usually
present before patients have any symptoms
are vague and nonspecific,
such as vague abdominal pain
and dull ache.
flank pain and hematuria, headache, and secondary
hypertension and recurrent renal colic pain.
schwannomas are usually solitary, well circumscribed,
firm, smooth-surfaced tumors
Histologically, schwannomas consist of compact
cellular lesions (Antoni type A tissue) and loose,
hypocellular myxoid lesions with microcystic spaces (Antoni
type B tissue).,
The hallmark pattern of the benign variants
is an alternation of these Antoni A and B areas,
with a diffuse positivity for S100 protein in the cytoplasm of the
shows , microfilament proteins and S-100
protein, which is the neural protein within the Schwann cell
Makes it easy to differentiates schwannomas from neurofibromas,
A variant of the typical schwannoma is the "ancient type"
or "degenerative neurilemoma" that presents with features
of degeneration, cystic changes and hyalinization
Malignant degeneration of schwannomas
is extremely rare, but when present, they act as high-grade sarcomas
with a high likelihood of producing local recurrence and distant metastasis.
Computed tomography(CT) scans typically show welldefined
low or mixed attenuation with cystic necrotic central
Cystic changes occur more commonly in retroperitoneal schwannomas (up to 66%) than in other retroperitoneal tumors.
Other degenerative changes, such as calcification, hemorrhage, and hyalinization, can also be present
been founded to be unreliable for the diagnosis of retroperitoneal schwannoma.
Risk of hemorrhage, infection, and tumor seeding; thus,
many authors do not recommend CT-guided biopsy.
surgical resection is the only accurate approach
for pathologic evaluation to enable diagnosis of retroperitoneal
Recent advances in laparoscopic instruments
and skills have made laparoscopy an excellent
approach for biopsy and even surgical resection of benign retroperitoneal tumors
Even though the best management of retroperitoneal
neural sheath tumors is complete excision,
controversy exists over negative soft tissue margins.
The argument here is that
the morbidity associated with resection of adjacent tissue
would not be justified in the treatment of a benign lesion
prognosis for retroperitoneal benign
schwannoma is extremely good
have been reported,
usually associated with von Recklinghausen‘s
disease.(*) There are a few reported cases in which
metastases occurred after resection of a histologically benign schwannoma.??
Therefore, it is suggested that careful
monitoring is necessary after removal of benign retroperitoneal Schwannomas
Ohigashi T, Nonaka S, Nakanoma T, Ueno M, Deguchi N. Laparoscopic
treatment of retroperitoneal benign schwannoma. Int J Urol