Treatment of idiopathic retroperitoneal fibrosis by immunosuppression

Neoplastic and proliferative disorders of the perinephric space

The perinephric space is a well-marginated central compartment of the retroperitoneum, located between the anterior and posterior pararenal spaces. Various neoplastic and proliferative disorders can affect the perinephric space, and there is a wide array of imaging findings. Although many perinephric lesions may extend directly from the kidney and adrenal gland, other lesions occur in the perinephric space due to haematogenous spread, as part of a systemic disease, or by extension from an adjacent retroperitoneal compartment. Imaging plays a pivotal role in the diagnosis of perinephric diseases, as many of the disease processes affecting this space will not result in clinical signs or symptoms until the disease is at an advanced stage. Despite the often shared non-specific clinical and imaging findings among these disease processes, application of a categorical differential diagnosis based on the imaging characteristics will serve to narrow the differential diagnosis and direct further evaluation and treatment. In this article, the lesions have been categorized as soft-tissue rind [nephroblastomatosis, fibrosis, Erdheim-Chester disease (ECD), extramedullary haematopoiesis, lymphoma, infiltrating metastases], focal solid lesions (extension of renal or adrenal malignancies, melanoma metastases, treated lymphoma), fat-containing lesions (angiomyolipoma, liposarcoma, myelolipoma), and cystic lesions (lymphangiomas, abscesses). The aim of this article is to demonstrate and describe the key imaging features of several neoplastic and proliferative disorders that affect the perinephric space.

Transmesocolic ureteral intraperitonealization: a new approach for laparoscopic treatment of retroperitoneal fibrosis

INTRODUCTION

Retroperitoneal fibrosis (RPF) is characterized by the presence of an inflammatory fibrotic process in the retroperitoneum causing compression of the retroperitoneal structures including the ureters. The ureterolysis is the liberation of the incarcerated portion of the ureter, from its proximal healthy portion to the distal portion, generally free of fibrosis, below the iliac vessels. We report the transmesocolic ureteral intraperitonealization as a new approach for laparoscopic treatment of RPF.

PATIENT AND METHODS

A 52-year-old female patient diagnosed with idiopathic RPF was submitted to laparoscopic transmesocolic ureteral intraperitonealization after medical management failure. An open access using a Hasson trocar was placed through the umbilicus and two additional trocars were placed-10  mm in the midline at 6  cm below the umbilicus and a 5  mm in the midline at 6  cm above the umbilicus. The left mesocolon was incised 3  cm lateral to aortic pulsation and the left ureter was identified and dissected off the retroperitoneal mass. Lateral incised mesocolon was mobilized and wrapped posterior to the left ureter using a running suture.

RESULTS

Operative time was 2 hours. The mean blood loss was less than 100  mL. The patient was discharged painless on the second postoperative day. No complications were observed. Pathology showed fibrous tissue. An intravenous pyelography was performed at 6 months after the surgery and showed no ureteral obstruction. Serum creatinine level stabilized at 0.9  mg/dL.

CONCLUSION

The transmesocolic ureteral intraperitonealization for laparoscopic treatment of RPF is feasible and can be considered a potential alternative for traditional laparoscopic intraperitonealization.

Retroperitoneal fibrosis: the clinical, laboratory, and radiographic presentation

Retroperitoneal fibrosis (RPF) is an inflammatory disorder that affects the infrarenal great vessels and surrounding structures. Although first described in 1948 by Ormond, much of the information currently available on this disease is conflicting and results from multiple definitions used by different investigators. We conducted the current study to describe the clinical, laboratory, and radiographic presentation of RPF from a single center using data collected in a prospective fashion.Data on all patients who were referred to our RPF clinic were prospectively collected. We obtained information on presenting signs and symptoms, and on the presence or absence of "traditional risk factors," comorbidities, and family histories. All patients underwent the same battery of laboratory testing, including complete blood count, renal function profile, erythrocyte sedimentation rate (ESR), thyroid-stimulating hormone, and antinuclear antibodies (ANA). All patients had contrast-enhanced computed tomography (CT) or magnetic resonance imaging (MRI) of the abdomen and pelvis. The extent of disease was classified based on the anatomic location of the soft-tissue density.Forty-eight patients (26 male and 22 female) met the criteria for RPF and were included in the study. The mean age was 54.25 years. Few patients had traditional risk factors for RPF. Pain and weight loss were the most common presenting symptoms. The mean hemoglobin was 11.6 g/dL. The mean ESR was 40.5 mm/h. Nine patients had positive ANA, all with negative antibodies to dsDNA. CT or MRI revealed the presence of a periaortic soft-tissue density in all (100%) patients; 69% had pericaval involvement, 62% had obstruction of 1 or both ureters, and 35% of patients had involvement of the renal artery or renal vein.In the current report we present the demographics and laboratory and radiographic presentation of a homogenous group of patients with RPF. We attempt to solidify a proper scheme of classification for the disease, and suggest an anatomic classification system that may be used for future studies.

Idiopathic retroperitoneal fibrosis: an unusual cause of low back pain

Retroperitoneal fibrosis (RPF) is a rare inflammatory disease which is characterized by the development of a fibrous process that surrounds the major vessels and organs located within the retroperitoneum. About two thirds of all cases of RPF are idiopathic and are thought to be immunological in origin. Diagnosis of RPF should be considered in patients with unexplained abdominal and low back pain and retroperitoneal lesions. We present a case report of a 59-year-old white male with idiopathic RPF with history of low back pain and weight loss as only symptoms and treated by tamoxifen, corticosteroids, and insertion of JJ endoureteric catheters due to the obstruction of the upper urinary tract.

[A 22 year old woman with fever, night sweats, weight loss and hepatomegaly]

A 22 year old female patient presented with fever, night sweats, weight loss and hepatomegaly associated with elevated inflammatory parameters and liver enzymes. Computer tomography revealed a mass located between the inferior vena cava and the psoas muscle as well as enlarged celiac, retroperitoneal and retrocaval lymph nodes. Biopsies of the retrocaval mass led to the diagnosis of retroperitoneal fibrosis. Within a few days of treatment with corticosteroids clinical presentation improved and imaging studies detected complete regression of the retrocaval mass after 6 months.

[Ureterolysis: technique, indications]

Ureteral obstruction due to idiopathic retroperitoneal fibrosis is a rare but severe clinical problem. The open approaches, as well as surgical techniques used to prevent stenosis recurrence, are described. Ureterolysis remains the procedure to relieve ureteral obstruction. The ureter is dissected and freed from the fibrotic process, and then separated to prevent the recurrence of the stenosis. Recently, the development of Laparoscopic urology has allowed for minimal invasive treatment of many urological problems. We present our technique of ureterolysis for extrinsic ureteral obstruction. Advantages and complications of each method are considered and indications are proposed.

Presentation of idiopathic retroperitoneal fibrosis in the pediatric population

Idiopathic fibrosis of the retroperitoneum is rare in childhood. The authors describe an 11-year-old boy who presented with progressive renal failure, bilateral hydronephrosis, hypertension, and elevated erythrocyte sedimentation rate (ESR) owing to retroperitoneal fibrosis. Ureterolysis was performed with improvement in his creatinine level and blood pressure. The soft tissue mass consisted of dense collagenous fibers consistent with retroperitoneal fibrosis. Postoperatively, he received steroids and azathioprine. Retroperitoneal fibrosis in the pediatric population is rare with only 23 cases reported in the English-language literature. Treatment includes pulsed steroid regimens, ureteral catheterization, and retroperitoneal exploration with ureterolysis. If allowed to progress, renal failure can result and lead to death. The etiology of retroperitoneal fibrosis in the pediatric patient may include autoimmune diseases, infection, and neoplasm, but most cases are idiopathic. Retroperitoneal fibrosis should be considered in patients with an elevated ESR, hypertension, renal failure, and hydronephrosis. Evaluation also should include a search for autoimmune diseases and malignancy.

Laparoscopic treatment of retroperitoneal fibrosis

BACKGROUND AND PURPOSE

Retroperitoneal fibrosis (RPF) is an uncommon cause of ureteral obstruction. Surgical treatment is required in most cases. Open ureterolysis, although effective, is associated with significant morbidity and mortality rates. We present data on a series of 13 patients undergoing laparoscopic ureterolysis for RPF.

PATIENTS AND METHODS

Between December 1994 and October 2000, 13 patients with RPF underwent laparoscopic ureterolysis at our institution. Operative time, complications, estimated intraoperative blood loss, time to oral intake, amount of parenteral analgesics used, and length of hospital stay were reviewed. Postoperative pyelography or diuretic urography was performed to assess ureteral patency.

RESULTS

Laparoscopic ureterolysis was successful in 11 patients (85%); two conversions to open surgery were needed (15%). One patient required a laparoscopic Boari flap on one side because of intense fibrosis. Four postoperative complications (30%) were managed with conservative measures. At a mean follow-up of 30 months, intravenous urography or renal scan showed relief of obstruction in 92% of the patients.

CONCLUSIONS

Laparoscopic ureterolysis is an option to treat RPF. It is not free of complications and failures, and its precise role in the treatment of RPF still needs to be judged with longer follow-up and larger number of patients.

Retroperitoneal fibrosis in four cats following renal transplantation

Four cats developed fibrosis within the retroperitoneal space following renal transplantation. In human transplant patients, retroperitoneal fibrosis is an uncommon complication following surgery and may be secondary to operative trauma, infection, deposition of foreign material in the operative field, urinary extravasation, and perirenal hemorrhage caused by trauma to the allograft. Possible causes of fibrosis in the cats of this report include abdominal inflammation associated with allograft rejection, pyelonephritis, and septic peritoneal effusion. All of the cats of this report were readmitted to the veterinary teaching hospital following renal transplantation because of recurrence of azotemia 1 to 5 months after transplantation. Abdominal ultrasonography revealed a 2- to 4-mm-thick capsule surrounding the allograft in 2 of 4 cats, hydronephrosis in 4 cats, and hydroureter proximally in 2 cats. An exploratory laparotomy was performed in all cats to remove the fibrotic tissue causing the ureteral obstruction. Normal renal function was restored in all cats following surgery. Histologic evaluation of biopsy specimens revealed smooth muscle (3 cats) and fibrous connective tissue (4). All 4 cats, regardless of the cause, responded well to surgical resection of the scar tissue that was causing a ureteral obstruction. None of the cats had recurrence of obstruction following surgery.

[Retroperitoneal pathology]

The retroperitoneum is one of the most complex regions of human anatomy as it contains a variety organs and structures from different systems, in particular those belonging to the urinary and digestive tracts and the vascular systems. The emergence of different diagnostic imaging techniques has made easier to study the retroperitoneum. Thanks to ultrasonography, computerised tomography and magnetic resonance the assessment of retroperitoneal conditions has taken a great leap forwards permitting the anatomical connections and characteristics of the structures in this region to be reliably established. Owing to the location in the retroperitoneal space of the different organs of the digestive tract and the vascular system, a multidisciplinary approach is required involving the different surgical specialties. The urologist performs a large proportion of his surgical activity in this region and must, therefore, have a good knowledge of the different retroperitoneal organs belonging to the urinary tract and also the connections between these and other organs and structures of the retroperitoneal region.

Follow-up of a case of retroperitoneal fibroses treated sequencially via right side autotransplant and left uterolysis with wrapper of posterior preperitoneal fat

We present a case of retroperitoneal fibrosis treated with a renal autotransplantation in a patient inicially treated with endourologic measures and corticotherapy without success. The extense ureteral affectation was the indication to carry out an autotransplant. The follow-up is of nine years, with the function of the renal unity still preserved. We checked the literature for the therapeutic possibilities, medical as much as surgical, of the retroperitoneal fibrosis with special attention to the usage of the refractory IRF to other treatments.

[Treatment of idiopathic retroperitoneal fibrosis]

Idiopathic retroperitoneal fibrosis is a rare disease and a delay in diagnosis may cause renal failure. Medical treatment i.e. corticotherapy or more recently, tamoxifene has been used successfully. This approach is recommended in patients either with moderate obstruction of the upper urinary, risk of major surgery or in cases of recurrence after surgical treatment. Ureterolysis using conventional surgery or laparoscopy remains the treatment of choice. This procedure should be considered in patients with neoplasic fibrosis, corticoresistant fibrosis or in cases of peri-aneurysm fibrosis.

Panhypopituitarism associated with severe retroperitoneal fibrosis

A 43-year-old man, with a history of central diabetes insipidus diagnosed 3 years previously, complained about reduced libido. An MRI scan showed a suprasellar lesion just below the supraoptic recess of the third ventricle. A stereotactically guided biopsy revealed fibrous glia, but no other specific tissue and no inflammatory cells. Two months later the patient presented with fatigue and muscular weakness. Tertiary adrenal failure and hypothyroidism were diagnosed by endocrine function tests and therapy with levothyroxine and hydrocortisone was started. Another 2 months later the patient was admitted with giddiness, nausea, peripheral oedema and oliguria. Radiological imaging and an open transperitoneal kidney exploration showed severe fibrosis around both ureters. Histological examination confirmed the diagnosis of idiopathic retroperitoneal fibrosis. Presumably the suprasellar tumour was the first manifestation of retroperitoneal fibrosis. Once the diagnosis 'idiopathic retroperitoneal fibrosis' is confirmed, fibrotic manifestations and complications involving extra-retroperitoneal tissues including the endocrine system, should be sought.

Idiopathic retroperitoneal fibrosis revisited

We have evaluated 21 patients, ranging in age from 44 to 71 years (mean: 55 years), who presented to our department with the radiologic characteristics of retroperitoneal fibrosis. Ureterolysis was performed in all cases. Intraperitoneal placement of the ureter was performed in 9, and placement of the ureter in a lateral extraperitoneal position in 12 cases. We found no difference in the postoperative course and radiological and clinical improvement to favour the first or the second method, and therefore we consider the intraperitoneal approach as an unnecessary manoeuvre.

Stenosis of the common bile duct due to Ormond's disease: case report and review of the literature

In a 46-year-old man endoscopic retrograde cholangiopancreatography and computed tomography scan showed a stenosis of the common bile duct by a hypodense mass highly suggestive of a Klatskin tumor. Histologic examination of the resected tumor revealed only non-specific inflammatory, fibrotic tissue without any evidence of malignancy. Three months later, the patient presented with hydronephrosis of the left kidney. Computed tomography scan showed a retroperitoneal mass with encasement of the left ureter. A percutaneous nephrostomy was performed and immunosuppressive therapy with prednisolone and azathioprine was initiated. Under this medication, almost complete regression of the pelvic mass and reopening of the ureter were observed within 3 weeks. Eight months later, azathioprine was withdrawn and prednisolone was tapered continuously to a dose less than 10 mg/day. After a follow-up of 2 years, the patient is still well. Although the histologic findings were non-specific, further evaluation of this case suggests that Ormond's disease was responsible for the tumor that had to be resected.

Fine-needle aspiration findings in idiopathic retroperitoneal fibrosis

Idiopathic retroperitoneal fibrosis (IRF) is an inflammatory and fibrosing process that can be complicated by periureteral encasement, ureteral obstruction, and subsequent renal failure if left untreated. Unfortunately, treatment is often delayed due to the nonspecific nature of the presenting signs and symptoms. Clinical, radiologic, and microscopic findings in IRF, if examined independently, are all nonspecific for its diagnosis. Rendering a diagnosis of IRF by fine-needle aspiration (FNA) requires supportive clinical and radiologic data and systematic evaluation of entities in the differential diagnosis. Herein we report 2 cases of IRF diagnosed by FNA with subsequent histologic confirmation. Smears prepared from the aspirates revealed a combination of inflammatory cells and fibrous tissue. The inflammatory component was comprised of a mixture of lymphocytes, plasma cells, and rare eosinophils and mast cells. These 2 cases represent, to our knowledge, only the second report of IRF diagnosed by FNA.

L'eziopatogenesi della fibrosi retroperitoneale: Etiopathogenesis of retroperitoneal fibrosis

The etiopathogenesis of retroperitoneal fibrosis is still obscure and probably multifactorial. Among the secondary forms due to demonstrable causes, the one caused by aorto-iliac atherosclerosis has recently been recognised. Its pathogenesis is linked to the low density oxidised lipoproteins of the atheromatous plaque, which are responsible for a local immunologic reaction. The most common form is still idiopathic or primitive, hypothetically related to genetic, environmental, vascular and/or immunologic factors. Idiopathic retroperitoneal fibrosis is sometimes associated with other sclerosing syndromes and/or systemic diseases. In such cases a common pathogenesis, probably immunologic may be postulated. After having illustrated the different categories of retroperitoneal fibrosis, the authors report their experience with 25 patients of whom 14 had idiopathic fibrosis and 11 secondary fibrosis. In the former group 11 patients (78.5%) smoked more than 10 cigarettes a day, while there was a history of prolonged professional exposure to asbestos in one case. The following associated pathologies were observed: hypertension in 7 cases (50%), ischemic cardiopathy in 2 (14.3%), diabetes mellitus in 2 (14.3%), multiple myeloma in 1 (7.1%) and juvenile rheumatoid arthritis in 1 (7.1%). The disease was also associated with other sclerosing pathologies in 3 cases: sclerosing cholangitis in 2 and Dupuytren's contracture in 1. The location of the fibrosis was typically periaortic in 13 cases (92.8%), as shown by CT. Lastly, 10 patients underwent immunosuppressive therapy with a favourable response, suggesting the probable immunologic pathogenesis of the disease.

La fibrosi retroperitoneale idiopatica. Terapia medica: Idiopathic retroperitoneal fibrosis. Medical treatment

Medicai treatment of both idiopathic and secondary retroperitoneal fibrosis (RPF) aims at stopping the inflammatory process in the early stage of the disease. Glucocorticoids and non-steroidal antiestrogen drugs are used. Methylprednisolone, the most commonly used glucocorticoid, is successfully employed with different therapeutic protocols. Although based on a few cases, results of treatment with tamoxifen are also satisfactory. The authors report 25 cases of RPF, idiopathic in 14 and secondary in 11. Twelve patients underwent medical therapy, corticosteroids being used in 10 and tamoxifen in 2. All patients recovered from the fibrotic disease. Only 1 patient stopped steroid therapy due to worsening diabetes. Easy administration and the lack of side effects make tamoxifen a valid alternative to corticosteroids.

[Regression of retroperitoneal fibrosis by combination therapy with tamoxifen and steroids]

BACKGROUND

Idiopathic retroperitoneal fibrosis is characterised by proliferation and fibrosis of retroperitoneal tissue. It is complicated by obstruction and encasement of retroperitoneal structures.

CASE REPORT

We describe two female patients with idiopathic retroperitoneal fibrosis. Both had to undergo lateralization of the ureter because of ureteral obstruction. Also both patients developed thrombosis of the inferior vena cava resp. the common iliac vein. Because of the eventful course of the disease a combined tamoxifen and steroid therapy was started. Hereafter there was a marked regression of the retroperitoneal fibrotic masses and the previous inflammatory signs disappeared.

CONCLUSION

Tamoxifen seems to be effective in the treatment of idiopathic retroperitoneal fibrosis by inducing a regression of the fibrotic masses. Especially in patients with continuous activity of the disease we recommend an additional steroid therapy to prevent a regeneration of the fibrosis.

Idiopathic retroperitoneal fibrosis presented as an abdominal mass and nephrotic syndrome

We present a 30-year-old male patient who was initially diagnosed as minimal change nephrotic syndrome, 5 years later, the patient developed a localized form of idiopathic retroperitoneal fibrosis (IRF). An elevated ESR and concomitant nephrotic syndrome in the patient suggested the immunologic nature of IRF, IRF has been reported in association with collagen diseases and rarely with proliferative and nonproliferative glomerulopathies. To our knowledge, the association between minimal change lesion (MC) and IRF has not been reported. Furthermore, the fact that IRF presented itself as an abdominal mass and lacked systemic symptoms was also unusual.

Due casi di fibrosi retroperitoneale con risposta favorevole alla terapia corticosteroidea

Retroperitoneal fibrosis is rare and is usually treated with exploratory laparotomy. Satisfactory response to corticosteroid therapy has been shown, however, in cases with early retroperitoneal disease, while those with late disease show no improvement. Two cases are reported of patients with retroperitoneal fibrosis treated successfully with long-term corticosteroid therapy.

What is orbital pseudotumor?

We have reviewed the literature in order to delineate the clinicopathologic definition of orbital pseudotumor, also called idiopathic nonspecific orbital inflammation. The clinical picture of orbital pseudotumor varies widely, with signs of mass effect, inflammation and/or infiltration. On computed tomography, orbital pseudotumor presents as a unilateral focal or diffuse mass. The histopathologic hallmark of orbital pseudotumor is a mixed inflammatory infiltrate with fibrosis of varying degree. Contrary to an old belief, orbital pseudotumor is not related to orbital reactive lymphoid hyperplasia (pseudolymphoma) and is not a lymphoid tumor. Atypical histopathologic findings of orbital pseudotumor include dominant sclerosis, granulomatous inflammation, vasculitis, and tissue eosinophilia. In the absence of systemic fibroinflammatory, granulomatous, and vasculitic disease, these atypical histopathologic patterns can be considered to represent subclasses of orbital pseudotumors rather then distinct entities. Clinical and prognostic characteristics of both histopathologically classical and atypical orbital pseudotumors appear to be heterogeneous. The etiology of orbital pseudotumor is unknown, but infection, autoimmune disorder, and aberrant wound healing have all been put forward as possibilities. In conclusion, orbital pseudotumor is one distinct disease albeit with many clinical and histopathologic guises.

Retroperitoneal fibrosis and juvenile rheumatoid arthritis

We describe a 13-year-old girl with juvenile rheumatoid arthritis who developed obstructive uropathy and renal failure. Retroperitoneal fibrosis (RPF) was confirmed by surgery. Although the renal failure and hydronephrosis resolved after surgery, the symptoms of vascular occlusion persisted. We consider that early diagnosis and treatment are essential. In cases of autoimmune disease, RPF should be considered when there is acquired obstructive uropathy accompanied by vascular occlusion syndrome.

Retroperitoneal fibrosis

— The etiology of retroperitoneal fibrosis has still not been clarified. We report our experence in support of the periaortitis hypothesis. Atherosclerosis of the aorta and Plaque rupture lead to liberation of the ceroid, through the awentitia into the periaortic tissue. This results in a chronic inflammatory process.

Retroperitoneal fibrosis. A true connective tissue disease

Retroperitoneal fibrosis, a disease that can occur at any age, is characterized by a periaortic fibrous mass that often surrounds the ureters, leading to ureteral obstruction. Patients who present with this disease may complain of flank pain and acute renal failure. There is a high correlation with atherosclerotic disease of the aorta, although the pathogenesis of this disease remains unknown. Although recommendations for therapy remain empiric, prednisone seems to be efficacious in treatment; tamoxifen also may be effective. Retroperitoneal fibrosis usually does not lead to long-term morbidity or affect survival.

Long-term follow-up of low-dose methotrexate therapy in one case of idiopathic retroperitoneal fibrosis

Idiopathic retroperitoneal fibrosis (RPF) is characterized by the development of a fibrotic mass surrounding the abdominal aorta and its branches, of unknown aetiology. Several immunological mechanisms can be operative in the pathogenesis of RPF. Based on this assumption we treated a patient affected by idiopathic RPF with low-dose methotrexate (MTX) therapy. To our knowledge this is the first example of the effectiveness and safety of a long-term low-dose MTX treatment in the post-surgical management of RPF.

Favourable results of a therapeutical scheme in idiopathic retroperitoneal fibrosis: Suggested protocol

— The Authors describe the favourable results obtained in 3 patients with Idiopathic Retroperitoneal Fibrosis (IRF) using a therapeutic protocol based on the association of prednisolone and cyclophosphamide. In 2 patients this therapy obtained a partial radiologic and total clinical remission; in the third case it guaranteed a stabilization of the results obtained by previous surgery. Given the absence of significant side effects, the protocol may be taken into consideration for practically all patients with TRF.

Response of renal intrahilar retroperitoneal fibrosis to immunosuppressive therapy

We report the case of a 37-year-old woman who developed renal failure secondary to obstruction by renal intrahilar retroperitoneal fibrosis. Her disease proved to be sensitive only to high-dose immunosuppression. Our case illustrates an unusual course of this disease and the role of immunosuppression in its management.

A case of uveitis associated with idiopathic retroperitoneal fibrosis

We treated a patient with nongranulomatous panuveitis associated with idiopathic retroperitoneal fibrosis who had symptoms of abdominal pain, severe fever, leg edema, and blurred vision. A high C-reactive protein level, a high erythrocyte sedimentation rate, anemia, and abnormalities of the immune system were seen. Retrograde pyelography disclosed persistent ureteral obstruction. A computed tomographic scan and magnetic resonance imaging showed a dense plaque of fibrous tissue around the kidney and hydronephrosis. Biopsy disclosed fibrosis infiltrated with lymphocytes, plasma cells, histiocytes, and eosinophils. A moderate degree of cellular inflammation in the anterior chamber and cystoid macular edema were present at ocular examination. We believe idiopathic retroperitoneal fibrosis to be a new cause of uveitis of suspected autoimmune origin.

Idiopathic sclerosing inflammation of the orbit. A distinct clinicopathologic entity

BACKGROUND

Idiopathic sclerosing inflammation of the orbit is a poorly delineated, fibrosing, immune-mediated entity resulting in significant ocular disability. To characterize this process and propose more specific and effective therapy, clinical and pathologic findings in 16 cases are reviewed.

METHODS

The clinical records of 16 patients with biopsy-proven disease were retrospectively reviewed to determine demographic and clinical features, radiologic features, course, management, and outcome. These findings were correlated with pathologic features to describe this unique entity. Immunohistologic characteristics were compared with those of a clinically and histopathologically similar process, retroperitoneal fibrosis.

RESULTS

The study included 11 male and 5 female patients, ranging in age from 8 to 81 years. Disease onset was usually unilateral (14/16) and chronic (11/15), with two distinct anatomic presentations, lacrimal (11/16) and apical (3/16), characterized by infiltration (15/16), mass effect (12/16), and visual loss (3/16). The most common signs and symptoms were dull pain (13/16), proptosis (11/16), mild inflammation (11/16), restricted motility (9/16), swelling (9/16), and diplopia (8/16). Two features, a sparse, chronic inflammatory infiltrate, the immunopathologic characteristics of which suggested a cell-mediated process, and a desmoplastic stroma of early onset, dominated the pathologic picture. Treatment with corticosteroids (11/16), radiotherapy for steroid failures (8/11), and observation alone (3/16) was inadequate, resulting in blindness in 3/16 cases, restricted movement in 10/16, and complete resolution in only 2/16 patients.

CONCLUSION

Idiopathic sclerosing inflammation of the orbit is a unique clinicopathologic entity, similar to retroperitoneal fibrosis, that is characterized by primary, chronic, and immunologically mediated fibrosis, poor response to corticosteroid treatment or radiotherapy, and frequent visual disability. Early and aggressive immunosuppressive therapy is recommended.