Treatment of Idiopathic Retroperitoneal Fibrosis With Colchicine and Steroids: A Case Series

Extravertebral low back pain: a scoping review

BACKGROUND

Low back pain (LBP) is one of the most common reasons for consultation in general practice. Currently, LBP is categorised into specific and non-specific causes. However, extravertebral causes, such as abdominal aortic aneurysm or pancreatitis, are not being considered.

METHODS

A systematic literature search was performed across MEDLINE, Embase, and the Cochrane library, complemented by a handsearch. Studies conducted between 1 January 2001 and 31 December 2020, where LBP was the main symptom, were included.

RESULTS

The literature search identified 6040 studies, from which duplicates were removed, leaving 4105 studies for title and abstract screening. Subsequently, 265 publications were selected for inclusion, with an additional 197 publications identified through the handsearch. The majority of the studies were case reports and case series, predominantly originating from specialised care settings. A clear distinction between vertebral or rare causes of LBP was not always possible. A range of diseases were identified as potential extravertebral causes of LBP, encompassing gynaecological, urological, vascular, systemic, and gastrointestinal diseases. Notably, guidelines exhibited inconsistencies in addressing extravertebral causes.

DISCUSSION

Prior to this review, there has been no systematic investigation into extravertebral causes of LBP. Although these causes are rare, the absence of robust and reliable epidemiological data hinders a comprehensive understanding, as well as the lack of standardised protocols, which contributes to a lack of accurate description of indicative symptoms. While there are certain disease-specific characteristics, such as non-mechanical or cyclical LBP, and atypical accompanying symptoms like fever, abdominal pain, or leg swelling, that may suggest extravertebral causes, it is important to recognise that these features are not universally present in every patient.

CONCLUSION

The differential diagnosis of extravertebral LBP is extensive with relatively low prevalence rates dependent on the clinical setting. Clinicians should maintain a high index of suspicion for extravertebral aetiologies, especially in patients presenting with atypical accompanying symptoms.

Retroperitoneal fibrosis is still underdiagnosed entity with poor prognosis

BACKGROUND

Retroperitoneal fibrosis (RPF) is a rare disease characterized by the presence of inflammatory and fibrous retroperitoneal tissue that often encircles abdominal organs including aorta and ureters. Data on the incidence of this disease are limited.

SUMMARY

The disease may be idiopathic or secondary to infections, malignancies, drugs or radiotherapy. Idiopathic form is an immune-mediated entity and a part of the broader spectrum of idiopathic diseases termed chronic periaortitis, characterized by a morphologically similar fibroinflammatory changes in aorta and surrounding tissues. Taking into account the dominant symptoms and clinical charac-teristics of patients with periaortitis, two subtypes of disease could be distinguished. Vascular subtype include patients with non-dilated aorta or with inflammatory abdominal aortic aneu-rysm, both with and without involvement of adjacent structures and with numerous risk factors for atherosclerosis. In renoureteral subtype obstructive uropathy manifesting with hydronephro-sis and acute kidney injury is predominant finding. Due to the variety of symptoms, diagnosis of RPF remains challenging, difficult and often delayed. A series of diagnostic tests should be performed, in order to confirm the diagnosis idiopathic RPF. Laboratory work-up include eval-uation of inflammatory indices and immunological studies. A biopsy and histopathological evaluation may be necessary to confirm diagnosis and differentiate the disease. Computed to-mography (CT), magnetic resonance imaging (MRI) and positron emission tomography (PET) are the modalities of choice for the diagnosis and follow-up of this disease. Management of ureteral obstruction, hydronephrosis, and aortic aneurysms often requires surgical evaluation and treatment. The pharmacological treatment of RPF has been evaluated in a few randomized trials and is mainly based on observational studies. Steroid therapy remains the gold standard of treatment. Key messages: Nowadays multidisciplinary team approach with clinical and diagnos-tic experience in both primary and secondary RPF as well as two major subtypes should be offered. Centers specialized in rare diseases with collaboration with other units and referral sys-tem yield the best possible outcomes.

Low-dose colchicine in type 2 diabetes with microalbuminuria: A double-blind randomized clinical trial

BACKGROUND

Neutrophil-related chronic inflammation (NRCI) may contribute to the pathogenesis of diabetic kidney disease (DKD). We evaluated whether blocking NRCI with low-dose colchicine prevents DKD.

METHODS

A double-blind, randomized, placebo-controlled study was conducted. A total of 160 patients with type 2 diabetes (T2D) and microalbuminuria (urinary albumin creatinine ratio [UACR] 30 to 300 mg/g Cr) who received angiotensin-converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARBs) for at least 3 months were included. Subjects were 1:1 randomized to a placebo or colchicine group (0.5 mg/day).

RESULTS

The primary end point was the incidence of overt nephropathy (UACR > 300 mg/g Cr). During the 36 months, 38 patients (51.4%) in colchicine group and 39 (54.1%) in the control group developed overt nephropathy (hazard ratio, 1.066; 95% confidence interval, 0.679-1.673; P = .78). Compared with placebo, colchicine modestly lowered levels of NRCI parameters (P values <.05 for high-sensitivity C-reactive protein, white blood cell counts, neutrophil counts, and neutrophil-to-lymphocyte ratio), whereas the changes of UACR and estimated glomerular filtration rate (eGFR) were similar between the two groups. There were no significant differences between the two groups in drug-related adverse events, including infection, gastrointestinal symptoms, and limb numbness.

CONCLUSIONS

In patients with T2D with microalbuminuria, low-dose colchicine effectively and safely lowered NRCI but did not prevent the incidence of overt nephropathy.

Atypical Presentation of Idiopathic Retroperitoneal Fibrosis Effectively Treated With Colchicine After Lymphoma Misdiagnosis

Idiopathic retroperitoneal fibrosis (RPF) is a rare disease characterized by a fibro-inflammatory mass encasing the abdominal aorta. We report a case of a 43-year-old man with an unusual presentation of RPF who was initially misdiagnosed with lymphoma. Our patient presented with constipation and did not have common findings such as ureteral displacement or renal impairment. Our patient had a complicated disease course complicated by multiple treatment failures and pulmonary embolism. We discuss the patient's first 100 months of treatment, which included the use of prednisone, mycophenolate, tamoxifen, methotrexate, azathioprine, and, now, colchicine. Our case demonstrates that physicians should maintain an index of suspicion for RPF in patients with a homogenously attenuated mass encasing the anterior aorta. It also serves as one example in which RPF appeared to be responsive to colchicine.

State of the Art Management of Aortic Valve Disease in Ankylosing Spondylitis

PURPOSE OF REVIEW

Cardiac involvement in patients with ankylosing spondylitis (AS) generally manifests itself as aortic insufficiency, aortitis, disturbance in cardiac conduction, and myocardial dysfunction. We have used a case-based approach to review the current state of the art knowledge regarding the diagnosis and management of aortic valve disease and aortitis in patients with AS.

RECENT FINDINGS

The risk for aortic valve disease and aortic valve replacement or repair is significantly higher than in people without AS, and this risk increases with age. Echocardiography, cardiac MRI, and CT can serve as effective tools for screening and follow-up. Surgical repair/replacement remains the mainstay of therapy for aortic insufficiency and aortic dilation, whereas transcatheter-based techniques may be favorable in the setting of aortic stenosis. Aortic valve and atrioventricular conduction abnormalities contribute to overall cardiovascular burden in AS. Optimal timing and therapeutic technique are dependent on assessment of overall risk and serial follow-up.

Extensive primary retroperitoneal fibrosis (Ormond's disease) with common bile duct and ureteral obstruction: A rare case report

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Retroperitoneal fibrosis is a rare inflammatory fibrotic process causing compression of retroperitoneal structures particularly the ureters.

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Ormond’s disease may involve the perirenal tissue, mesentery and biliary system in extremely uncommon situations defining the extensive RPF.

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We describe an unusual case of retroperitoneal fibrosis presenting as a malignant tissular bile duct stricture (hilar cholangiocarcinoma).

Introduction

Idiopathic retroperitoneal fibrosis (Ormond’s disease) may involve the perirenal tissue, mesentery and biliary system in extremely uncommon situations in addition to classical compression of retroperitoneal structures particularly the ureters.

Presentation of case

We report the case of a 60 year’s old man with clinical manifestation of obstructive jaundice, due to the common bile duct narrowing caused by a primary retroperitoneal fibrosis. Magnetic resonance cholangiopancreatography (MRCP) showed the presence of intrahepatic bile duct obstruction, suggesting the diagnosis of a hilar cholangiocarcinoma. Endoscopic retrograde cholangiopancreatography (ERCP) showed strictures in the proximal common bile duct. A biliary endoprosthesis was inserted at ERCP. Histological investigations as well as CT-scan were compatible with retroperitoneal fibrosis.

Discussion

The main clinical presentation of the Ormond’s disease is compression of the ureters, and less commonly blood vessels and nerves. Our patient presented with obstructive jaundice, due to the common bile duct (CBD) compression, which was unusual. The first description of the extrahepatic biliary obstruction secondary to retroperitoneal fibrosis was made in 1964 and since then only 13 cases have been reported in the medical literature.

Conclusion

Retroperitoneal fibrosis can cause compression of the CBD and therefore mimic a cholangiocarcinoma. Patients can be successfully managed with long-term CBD stent placement.

Management of idiopathic retroperitoneal fibrosis from the urologist's perspective

INTRODUCTION

Idiopathic retroperitoneal fibrosis (IRF) is a rare disease characterized by a fibrotic reaction that affects retroperitoneal organs, especially the urinary tract. In this review we analyze the current imaging techniques, morphological characteristics, clinical aspects and therapeutic aspects of idiopathic retroperitoneal disease.

METHODS

A PubMed search was conducted in December 2013 to find original articles, bibliographic reviews and series reports published in the past 15 years on idiopathic retroperitoneal fibrosis, its management and outcomes by combining terms like retroperitoneal fibrosis, periaortitis, treatment and autoimmune. A total of 89 articles were included in this review that referred strictly to IRF. We analyzed the imaging tools used for diagnostic and the decision making protocol used by physicians in the management of IRF.

RESULTS

A computerized tomography (CT) scan represents the most commonly used imaging technique for diagnosis. Magnetic resonance imaging (MRI) is unable to differentiate more accurately between benign and malignant retroperitoneal fibrosis (RF) than a CT scan. Biopsy remains the most reliable diagnostic tool for IRF. However, the histological characteristics of IRF are not yet well-defined and the protocol for biopsy is not standardized in terms of template, number of biopsies and the immunohistochemical panel needed for positive diagnosis. The most common treatment reported is corticosteroid therapy alone or in combination with other immunosuppressants, whereas surgical treatment is reserved for severe cases. Indwelling ureteric stents represent the most common procedure for renal drainage, but their efficacy is questionable. Open ureterolysis remains the gold standard for surgical treatment, but its purpose is only to resolve the ureteric obstruction, not to treat the retroperitoneal fibrosis. Laparoscopic and robotic approaches have been reported to be feasible, but no prospective, comparative trials have been performed due to the rarity of the disease. Surgical technique is not standardized and the outcome of the treatment only evaluates the recovery of the renal function.

CONCLUSIONS

The imaging procedures available today are unable to accurately differentiate between idiopathic and malignant RF. A biopsy is mandatory to confirm the diagnosis, but there is no consensus regarding the template, timing and number of biopsies needed to exclude malignancy. Open ureterolysis represents the main surgical treatment for cases with severe IRF, and laparoscopic or robotic approach may be an option in selected cases. The recovery of the renal function is a surrogate for evaluating the success of the treatment. More clinical studies are needed in order standardize the protocol for diagnostic, treatment and follow up after medical or surgical management.

[Chronic periaortitis]

Chronic periaortitis is an inflammatory and fibrosing disease presenting as periaortal fibrosis and formation of aortic aneurysms which are mostly localized in the retroperitoneum and occasionally in the mediastinum. Inflammatory vasculitic involvement of large vessels is also possible. In addition to symptoms of systemic inflammation, mechanical complications also occur whereby obstruction of the ureter is the most frequent. The diagnosis is made by contrast-enhanced computed tomography (CT) or magnetic resonance imaging (MRI) and if the findings are atypical the diagnosis should be confirmed by biopsy. After exclusion of a secondary genesis, in which case therapy of the underlying illness would be necessary, idiopathic chronic periaortitis can be treated with steroids. In cases of refractory and relapsing courses the administration of further immunosuppressive medication can be necessary. Duration of therapy, dosage and indications for immunosuppressive medication are currently unclear and have to be defined in further randomized controlled trials with larger cohorts. If complications occur, interventional or operative treatment can be necessary; in cases of hydronephrosis the placement of double-J-stents is usually sufficient.

Retroperitoneal fibrosis

Retroperitoneal fibrosis (RPF) is a condition characterized by the presence of inflammation and fibrosis in the retroperitoneal space, for which no standard diagnostic criteria exist. Historically, treatment has focused on relieving the obstruction with percutaneous or cystoscopic assisted placement of ureteral stents followed by more definitive resolution of ureteric obstruction with open or laparoscopic ureterolysis. However, over the past several years management has shifted from primarily a surgical approach to an immunosuppressive-based therapy aimed at modulation of the immune system. This review focuses on the recent advances in the classification, epidemiology, pathophysiology, pathology, imaging, and treatment of RPF.

Retroperitoneal fibrosis: single-centre experience from 1992 to 2010, current status of knowledge and review of the international literature

OBJECTIVE

The aims of this study were to investigate retroperitoneal fibrosis in a Spanish hospital and present a review of the international literature to attempt to elucidate a diagnostic and therapeutic approach to this unusual pathology.

MATERIAL AND METHODS

A database search was performed in the pathology department and in the documentation service using the key words "retroperitoneal fibrosis" and "Ormond's disease", limiting the search to the years 1990-2010. Cases in which secondary retroperitoneal fibrosis was considered were excluded. In addition, a PubMed literature search was performed using the terms "retroperitoneal fibrosis" and "Ormond's", limiting the search to 1985-2011.

RESULTS

Twenty-two patients were diagnosed with idiopathic retroperitoneal fibrosis (IRF) or Ormond's disease. The most common symptom at the time of diagnosis was flank pain. With regard to laboratory findings, five patients (22.7%) had anaemia and eight (36.3%) had renal failure. Computed tomography (CT) was performed in 20 patients (90.9%) and the most common finding observed was retroperitoneal mass. Eighteen patients were started on corticosteroids, in six cases in association with azathioprine. Three patients had recurrence at 12, 24 and 72 months, respectively, and 15 patients required emergency surgery. Nine open surgical procedures were performed.

CONCLUSIONS

At present, IRF is considered an autoimmune disease that presents with local and systemic signs and symptoms. CT and magnetic resonance imaging are the two tests of choice in IRF diagnosis and follow-up. [(18)F]Fluorodeoxyglucose positron emission tomography is starting to be used for assessment and treatment response. A combination of medical and surgical treatment is usually applied. It is essential to administer corticosteroids alone or in association with other immunosuppressive drugs such as azathioprine. Laparoscopic ureterolysis, or robotic ureterolysis, if available, is the technique of choice.

CCL18 -- potential biomarker of fibroinflammatory activity in chronic periaortitis

OBJECTIVE

Promising therapeutic approaches have emerged in chronic periaortitis, whereas peripheral blood biomarkers are lacking. CC-chemokine ligand 18 (CCL18) is known as a marker of fibrotic activity and prognosis in pulmonary fibrosis. We investigated whether CCL18 levels are increased in patients with chronic periaortitis and are associated with clinical, laboratory, and imaging findings.

METHODS

In this retrospective study, serum concentrations of CCL18 were assessed in 30 patients with chronic periaortitis and related to clinical data, laboratory variables, and imaging studies. Serum levels were compared to 15 apparently healthy volunteers and 15 controls with aortic sclerosis.

RESULTS

Serum concentrations of CCL18 were increased in patients with chronic periaortitis (median 197.6 ng/ml, range 73.7-301.0) compared to healthy volunteers (median 34.6 ng/ml, range 22.6-70.4; p < 0.0001) and controls with aortic sclerosis (median 50.4 ng/ml, range 24.5-141.2; p < 0.0001). CCL18 levels correlated with (n = 30; r = 0.461, p = 0.01) and increased with the transversal diameter of the periaortic mantle < 5, 5-10, and ≥ 10 mm (p = 0.008). Contrast enhancement (p = 0.044), treatment naivety (p = 0.042), and the occurrence of systemic symptoms (p = 0.007) were associated with higher CCL18 levels. During followup, changes of CCL18 correlated with changes of the transverse diameter of the periaortic mantle (n = 17; r = 0.512, p = 0.033).

CONCLUSION

Serum concentration of CCL18 reflects fibroinflammatory activity and extent of disease in patients with chronic periaortitis.

[¹⁸F]FDG-PET/CT in patients affected by retroperitoneal fibrosis: a bicentric experience

PURPOSE

The aim of our study was to assess the feasibility and usefulness of 2-[(18)F]-fluoro-2-deoxy-D: -glucose positron emission tomography computed tomography ([(18)F]FDG-PET/CT) in patients affected by retroperitoneal fibrosis.

MATERIALS AND METHODS

We retrospectively evaluated 25 patients studied in two centers: 18 underwent [(18)F]FDG-PET/CT as initial evaluation, three during follow-up, three during steroid therapy, and one to re-evaluate the disease. Among the group who underwent initial evaluation, ten underwent a second [(18)F]FDG-PET/CT after steroid therapy.

RESULTS

[(18)F]FDG-PET/CT was positive in 18 patients and negative in seven. Among the ten patients who underwent a second study after steroid therapy, six showed complete metabolic response, three partial response, and one no significant maximum standardized uptake value (SUV(max)) reduction.

CONCLUSION

Our preliminary results show that [(18)F]FDG-PET/CT is feasible and suitable for evaluating retroperitoneal fibrosis and is useful in assessing therapy response. Larger studies are desirable to confirm these findings and to determine the appropriate position of [(18)F]FDG-PET/CT in the diagnostic flow chart for this disease.

Aortitis and periaortitis in ankylosing spondylitis

Aortic involvement is a potential life-threatening complication of ankylosing spondylitis, usually occurring late in the course of this frequent disease. Inflammatory lesions evolving to fibrosis are primarily localized in the aortic root causing regurgitation, but this process can extend into the left atrium (subaortic bump) involving the mitral valve and the heart conduction system. First, second and third degree atrioventricular blocks are the most common conduction alterations described and they can be temporary. Chronic periaortitis has been described in ankylosing spondylitis patients. This disease is characterized by inflammation evolving to fibrosis and it is localized in the periaortic and peri-iliac retroperitoneum. It causes compressive effects on ureters and venous, arterial and lymphatic vessels. Its treatment employs endoscopic and/or surgical procedures and administration of corticosteroids, even in association with immunosuppressive agents. Both aortitis (with conduction system alterations) and periaortitis should be kept in mind by the physicians because they can significantly influence the prognosis of ankylosing spondylitis patients and they can need a rapid treatment.

Positron emission tomography as a tool for the 'tailored' management of retroperitoneal fibrosis: a nephro-urological experience

BACKGROUND

Retroperitoneal fibrosis (RF) is a complex clinical entity characterized by a fibro-inflammatory reaction around the abdominal aorta and iliac arteries extended into the retroperitoneum. No biochemical marker correlates with the disease severity and progression, and imaging data fail to discriminate between fibrotic and florid lesions. Positron emission tomography (PET) was recently suggested as a promising tool to detect the disease.

METHODS

We report on seven consecutive cases of RF managed by tailoring therapeutic interventions to the metabolic activity detected by PET. In 2006-09, seven patients with RF (five new diagnoses) were referred to the same nephro-urological facility. There were six males and one female aged 41-79. RF was associated with autoimmune diseases in three patients, with an aortic aneurysm in another three, and was 'idiopathic' in one. The diagnoses were made by imaging techniques [computed tomography (CT) or nuclear magnetic resonance (NMR)]; PET scan was performed in all patients in the same setting at referral and during follow-up.

RESULTS

Patients were followed up with tailored interventions (medical therapy: tamoxifen, steroids, and immunosuppressors according to disease activity, side effects and tolerance). Six patients needed ureteral stenting for obstruction. PET imaging was used as a guide for the tapering of immunosuppressors and for stent removal. In this way, stents were safely removed when a negativization of disease activity was revealed by PET. Only one relapse was recorded over 163 months of follow-up (median 24 months) detected in time by PET.

CONCLUSION

PET is a promising tool for surveillance of disease activity and for planning the removal of ureteral stents in RF.

Association between Familial Mediterranean Fever and Retroperitoneal Fibrosis: Retroperitoneal Fibrosis Regression after Colchicine Therapy

Retroperitoneal fibrosis (RPF) is a disease characterized by inflammatory fibrotic processes affecting the retroperitoneal structures. Familial Mediterranean Fever (FMF) is an autosomal recessive disorder, characterized by fever and attacks of sterile serositis. Colchicine is the only suitable drug for prevention of acute episodes. We describe a case of association between RPF and FMF in a 48-year-old male, in whom therapy with colchicine, besides preventing acute episodes, allowed RPF regression. To date the association between FMF and RPF and the use of colchicine therapy alone for RPF has not been described.