PRESUS TUMOR RETROPERITONIAL.docx

8/11/2019 PRESUS TUMOR RETROPERITONIAL.docx

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PRESENTASI KASUS

Pria umur 36 tahun dengan benjolan di perut dan inguinal

Disusun Oleh

Galih Arya Wijaya

20090310130

Diajukan Kepada :

Dr. Sutikno Sp. B

ILMU BEDAH

RSUD MUNTHILAN

FAKULTAS KEDOKTERAN DAN ILMU KESEHATAN

UNIVERSITAS MUHAMMADIYAH YOGHYAKRTA

2013


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Leher: tidak ada benjolan dan pembesaran kalenjer limfe

Thorax

Jantung : s1, s2 reguler, gallop(-), murumur(-)

Paru : vesikuler(+/+), bronki (-/-), wheezing (-/-)

Abdomen

Inspeksi : Massa pada regio abdomen dengan ukuran 20x20x10, benjolan pada regio

inguinal 3x10cm

Auskultasi : bising usus (+), .metalic sound (-)

Palpasi : massa keras, immobile, nyeri (-)

Perkusi : pekak (+)

Ekstremitas

DBN

IV. PEMERIKSAAN LABORATORIUM

AL : 13,51 ribu/ul

Hb : 10,5g /dl

Eritrosit : 4,1juta/ul

MCV : 75,1 fl

MCH : 25,6 pg

MCHC : 34,1 g/dL

Trombosit : 408 ribu /ul

Ureum : 44

Creatinine : 1,08

EKG : normal ECG

USG Abd : Sugestif Tumor Omentum

V.

DIAGNOSIS

Pre-Op:

Tumor Omentum

Post-Op:

Tumor retroperitonial post laparotomy

Biopsi eksisi


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VI. PENATALAKSANAAN

Laparatomi

IVFD RL 20 tpm

Ceftriaxone 2x1 gr

Kalnex 3x1 500mg

Ketorolac 3x30mg

Ranitidine 2x1 amp


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VII. PEMBAHASAN

Retroperitonial tumors are malignant and arise from a mesenquimatous origin.

Usually involving important anatomical structures such as main abdominal vessels

and organs, their radical approach often necessitates major resections of these

viscera.

Surgery of the inferior vena cava

I nfer ior vena cava involvement by primary and secondary tumors has been

traditi onally considered an unresectabil ity cr iterion. Cur rently, thanks to the

technical development of surgery (mainly after liver transplantation

development) and the creation of new prosthetic materials for vascular repair ,inferior vena cava resections are feasible and safe in a selected group of

patients.

The retroperitoneum is the anatomical space limited by the peritoneum at the

front, the abdominal wall at the back, the twelfth rib at the top, and the sacrum and

crest of the ileum at the lower side. Some organs, such as the kidneys, ureters, and

adrenal glands are located in this space.

The primary retroperitoneal tumors develop a great variety of neoplasia due to

their histogeny. Most primary retroperi toneal tumors are mali gnant and have a

mesenchymal or igin .They represent the 0.3% to 0.8% of all types of neoplasia.

Their clinic occurrences are seldom and not precise, but when present, the

retroperitoneal tumors normally appear in later stages and are caused by

compression or movement of organs or near-by structures.

The liposarcoma is the most frequent malignant retroperi toneal tumorand is one

of the most common sarcomas among all possible locations (25-35%).

The pleomorph ic and l ipomatous are the most usual types. The malignant

fibrous histiocytoma is a common neoplasy in the elderly and in extremities of

soft tissue. In the retroperitoneum, the most frequent histological variety is the


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pleomorphic one. The leiomyosarcoma can be present at different locations and

the evaluation of the number of atypical mitosis prior to evaluating the

retroperitoneal tumors malignancy is necessary.

Those retroperi toneal tumors located in the retroper itoneum have a bigger size,

indicating malignancy itself. They frequently present Schimmelbusch's disease

and necrosis.

The schwannomas or nerve sheath tumors can appear at any age, and those located

in the retroperitoneal area usually present a big size. Morphologically speaking,

they can be identified by the presence of fusiform, wavy cells that tend to form

palisades. Chromaffinomas are tumors formed in chromaffin-cell groups and they

synthesize catecholamines and other amines. They are connected to the

sympathetic and parasympathetic nervous systems. The tumors originated in these

structures are called chromaffinomas. Extra-adrenal chromaffinomas are present

in the midline, especially in the upper or lower para-aortic region. One of the most

frequent origins is the Zuckerkandl organ. Extraadrenal chromaffinomas are

usually functional: they produce high levels of catecholamine and are responsible

for clinic manifestations such as arterial hypertension.

I n most cases, the presence of germinal retroperi toneal tumors represents

metastasis of pr imary gonad tumors. In adults, the most frequent types are the

seminoma, followed by the embryonic carcinoma and teratoma. In children,

mature and immature, teratomata are more frequent, whereas the embryonic

carcinoma and the endodermic sinus tumor are less common. Signs and symptoms

are generally quite unspecific and they appear due to the compression of the

structure of nearby organs.

Radiologic explorations, helical computed tomographies and resonance

angiographies facilitate the diagnosis of the injury as well as its vascular

connections.


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The involvement of the inferior vena cava in tumoral processes has been

considered for a very long time an unquestionable reason for surgical inoperability

or unresectability.

The great dif fi culty of this technique and the unclear ri sk/benefit relation are

important reasons which determine this attitude.

The important progress made in the last two decades for the in ferior vena cava

surgery (most of them thanks to liver transplant) and the use of new prosthetic

materials have permitted vena cava resections, with or without substitute

prosthesis, as a therapeutic alternative for patients with locally-advanced tumoral

diseases. Thus, a therapeutic approach may be offered to a particular number of

patients with a curative intention.

Our exper ience in resection of the inf er ior vena cava fol lowing diff erent process

goes up to 20 dif ferent cases.The indications for their performance were:

- Liver metastasis from colorectal carcinoma

- Intrahepatic cholangiocarcinoma

- Renal carcinoma

- Inferior vena cava tumoral thrombosis from renal carcinoma

- Inferior vena cava primary tumors

- Retroperitoneal tumors with involvement of the inferior vena cava

- Liver hydatid disease with involvement of the inferior vena cava and consequent

thrombosis

In 40% of the cases described, a resection of the in ferior vena cava and a

restitution of the systemic vascular flow were performed thanks to a ring

prosthesis 20 mm diameter. In most cases, a saphenous-femoral arterio-venous

fistula was added in order to increase venous flow in the prosthesis.

The resul ts obtained, in terms of surgical morbimor tali ty, permeabil ity of the

substi tute prosthesis, and long, medium and shor t term sur vival rates justify thi s

kind of surgical procedures in a parti cular number of patients in which a

venous excision might be requir ed for the complete resection of the tumor. As


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long as the characteristics of the tumor require it, following chemoradiotherapy

completes the therapeutic treatment.

The retroperitoneum represents a complex potential space with

multiple vital structures bounded anteriorly by the peritoneum, ipsilateral colon

and mesocolon, pancreas, liver or stomach. The posterior margins are by large

composed of the psoas, quadratus lumborum, transverse abdominal and iliacus

muscles but, depending on the tumour location and size, may be formed by the

diaphragm, ipsilateral kidney, ureter and gonadal vessels. Similarly, the medial

boundaries may include the spine, paraspinous muscles, the inferior vena cava

(for right-sided tumours) and the aorta (for left-sided tumours). The lateral margin

is formed by the lateral abdominal musculature and, depending on tumour

location, may include the kidney and colon. Superiorly, retroperitoneal tumours

may be in contact with the diaphragm, the right lobe of the liver, the duodenum,

the pancreas or the spleen. The inferior margin may relate to the iliopsoas muscle,

the femoral nerve, the iliac vessels or pelvic sidewall.5

Due to the inaccessibility of the region and since these tumours often give

no or non-specific symptoms until they have reached a substantial size, they are

usually large at presentation.4Sarcomas comprise a third of retroperitoneal

tumours, with two histological subtypes predominating, namely liposarcoma

(70%) and leiomyosarcoma (15%).6Other retroperitoneal neoplasms include

primary lymphoproliferative tumours (Hodgkin's and non-Hodgkin lymphoma)

and epithelial tumours (renal, adrenal, pancreas) or might represent metastatic

disease from known or unknown primary sites (germ cell tumours, carcinomas,

melanomas) (Fig 2).6Benign tumours can cause concern and are often an

incidental finding during an investigation for unrelated symptoms. They may be

referred on suspicion of being a sarcoma. The most common benign pathologies

encountered in the retroperitoneum include benign neurogenic tumours

(schwannomas, neurofibromas), paragangliomas (functional or non-functional),

fibromatosis, renal angiomyolipomas and benign retroperitoneal lipomas tracts

are often displaced, they are rarely invaded and gastrointestinal or urinary

symptoms are unusual.
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