Retroperitoneal fibrosis (Ormond's disease): clinical pathologic study of eight cases

A retrospective analysis of perioperative complications of lateral approach lumbar interbody fusion in patients with prior abdominal surgery or a history of colonic inflammatory disease

BACKGROUND CONTEXT

Lateral approaches for lumbar interbody fusion (LIF) allow for access to the lumbar spine and disc space by passing through a retroperitoneal corridor either pre- or trans-psoas. A contraindication for this approach is the presence of retroperitoneal scarring that may occur from prior surgical intervention in the retroperitoneal space or from inflammatory conditions with fibrotic changes and pose challenges for the mobilization and visualization needed in this approach. However, there is a paucity of evidence on the prevalence of surgical complications following lateral fusion surgery in patients with a history of abdominal surgery.

PURPOSE

The primary aim of this study is to describe the association between surgical complications following lateral interbody fusion surgery and prior abdominal surgical.

STUDY DESIGN

Retrospective study.

PATIENT SAMPLE

Patients over the age of 18 who underwent lateral lumbar interbody fusion at a large, tertiary care center between 2011 and 2019 were included in the study.

OUTCOME MEASURES

The primary outcome included medical, surgical, and thigh-related complications either in the intraoperative or 90-day postoperative periods. Additional outcome metrics included readmission rates, length of stay, and operative duration.

METHODS

The electronic health records of 250 patients were reviewed for demographic information, surgical data, complications, and readmission following surgery. The association of patient and surgical factors to complication rate was analyzed using multivariable logistic regression. Statistical analysis was performed using R statistical software (R, Vienna, Austria).

RESULTS

Of 250 lateral interbody fusion patients, 62.8% had a prior abdominal surgery and 13.8% had a history of colonic disease. The most common perioperative complication was transient thigh or groin pain/sensory changes (n=62, 24.8%). A multivariable logistic regression considering prior abdominal surgery, age, BMI, history of colonic disease, multilevel surgery, and the approach relative to psoas found no significant association between surgical complication rates and colonic disease (OR 0.40, 95% CI 0.02-2.22) or a history of prior abdominal surgeries (OR 0.56, 95% CI 0.20-1.55). Further, the invasiveness of prior abdominal surgeries showed no association with overall spine complication rate, lateral-specific complications, or readmission rates (p>.05).

CONCLUSION

Though retroperitoneal scarring is an important consideration for lateral approaches to the lumbar spine, this study found no association between lateral lumbar approach complication rates and prior abdominal surgery. Further study is needed to determine the impact of inflammatory colonic disease on lateral approach spine surgery.

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.

Rituximab in the management of retroperitoneal fibrosis: A single tertiary rheumatology care center experience

AIM

To investigate the clinical and radiological outcomes and glucocorticoid-sparing effect of rituximab therapy in 13 patients with retroperitoneal fibrosis (RPF).

METHODS

We analyzed the data of both glucocorticoid-naive and glucocorticoid-resistant RPF patients who were treated with rituximab. Demographic features, positron emission tomography computed tomography (PET-CT) findings, and clinical and histopathologic outcomes were collected retrospectively.

RESULTS

We evaluated the data of 13 RPF patients (8M/5F). The median follow-up duration was 28 months (interquartile range [IQR] 24.5-55.5 months) and median age at the time of diagnosis was 50.8 years (IQR 46.5-54.5 years). PET-CT scans showed that following the rituximab therapy, the craniocaudal diameter of the RPF mass reduced from 74 mm (IQR 50.5-130 mm) to 52 mm (IQR 35-77 mm; p = .06), and periaortic thickness of the RPF mass reduced from 14 mm (5.5-21.9 mm) to 7 mm (4.5-11 mm; p = .12). The maximum standardized uptake value (based on body weight) of the RPF mass decreased from 5.8 (4.3-9.7) to 3.1 (2.8-5.3) after the therapy (p = .03). The number of patients with hydronephrosis reduced from 11 to 6 following rituximab therapy (p = .04). Before rituximab, nine patients received a median dose of 10 mg (IQR 0-27.5 mg) prednisolone per day. After the rituximab treatment, we discontinued prednisolone treatment for four out of nine patients and reduced the daily dose for the remaining patients. At the time of the final evaluation of the patients, the median prescribed prednisolone dose was 5 mg/day (IQR 2.5-7.5 mg/day; p = .01).

CONCLUSION

Our study shows that rituximab may be a favorable treatment option for glucocorticoid-refractory RPF patients with high disease activity on PET-CT scans.

Malignancy diseases and kidneys: A nephrologist prospect and updated review

Acute kidney injury (AKI), chronic renal failure, and tubular abnormalities represent the kidney disease spectrum of malignancy. Prompt diagnosis and treatment may prevent or reverse these complications. The pathogenesis of AKI in cancer is multifactorial. AKI affects outcomes in cancer, oncological therapy withdrawal, increased hospitalization rate, and hospital stay. Renal function derangement can be recovered with early detection and targeted therapy of cancers. Identifying patients at higher risk of renal damage and implementing preventive measures without sacrificing the benefits of oncological therapy improve survival. Multidisciplinary approaches, such as relieving obstruction, hydration, etc., are required to minimize the kidney injury rate. Different keywords, texts, and phrases were used to search Google, EMBASE, PubMed, Scopus, and Google Scholar for related original and review articles that serve the article's aim well. In this nonsystematic article, we aimed to review the published data on cancer-associated kidney complications, their pathogenesis, management, prevention, and the latest updates. Kidney involvement in cancer occurs due to tumor therapy, direct kidney invasion by tumor, or tumor complications. Early diagnosis and therapy improve the survival rate. Pathogenesis of cancer-related kidney involvement is different and complicated. Clinicians' awareness of all the potential causes of cancer-related complications is essential, and a kidney biopsy should be conducted to confirm the kidney pathologies. Chronic kidney disease is a known complication in malignancy and therapies. Hence, avoiding nephrotoxic drugs, dose standardization, and early cancer detection are mandatory measures to prevent renal involvement.

Retroperitoneal Sclerosing Lipogranuloma in an Adolescent With Congenital Atresia of the Inferior Vena Cava: Case Report and Literature Review

Sclerosing lipogranuloma (SLG) in children is a rare, benign disease of unknown etiology suspected to be due to abnormal fatty tissue reaction. A 13-year-old girl presented with progressively worsening back pain. Cross-sectional imaging identified a retroperitoneal mass compressing the left ureter as well as infrarenal inferior vena cava atresia with extensive venous collaterals and chronic partially occlusive thromboses of the iliac veins. Surgical biopsy was consistent with SLG and it resolved spontaneously. SLG is typically a disease of adulthood but may be seen in children. The association between inferior vena cava atresia with venous thrombosis and development of SLG has not been reported previously.

[Retroperitoneal fibrosis in adults: Diagnostic approach based on a retrospective multicenter study on 32 cases]

INTRODUCTION

Retroperitoneal fibrosis is a rare disease, typically with an insidious and various clinical course. The peak incidence is seen in patients 40 to 60 years of age and mostly in man. The characteristic finding in this disease is a periaortic fibrous mass that often surrounds the ureters. The diagnostic approach remains uncodified. We aimed to determine the different clinical, radiological and biological aspects of retroperitoneal fibrosis.

PATIENTS AND METHODS

Retrospective multicenter study of 32 retroperitoneal fibrosis cases hospitalized between 1999 and 2014 in the Internal Medicine Department and Urology Department in the university hospital center Sahloul Sousse.

RESULTS

There were 24 men and 8 women with a mean age of 58 years. The lumbar pain is the most common clinical signs (53.1%). An inflammatory syndrome and renal failure were the most common biological signs. The diagnosis was suspected on data from the abdominal ultrasound and confirmed by pelvic CT scan that showed a periaortic fibrous mass that often surrounds the ureters. Histological analysis of a surgical biopsy specimen was performed in only eight cases.

CONCLUSION

The most common mode of presentation of retroperitoneal fibrosis remains lumbar pain with renal failure and a high sedimentation rate. Although abdominal ultrasound may contribute to the general evaluation of patients with retroperitoneal fibrosis, CT-scanner is the preferred imaging method. The imaging capability of magnetic resonance and the TEP-scan may facilitate assessment of disease extent.

LEVEL OF EVIDENCE

4.

Malignant retroperitoneal fibrosis: MRI characteristics in 50 patients

We analyzed magnetic resonance imaging (MRI) morphologic patterns of retroperitoneal fibrosis (RF) to identify those able to distinguish malignant RF (mRF) from idiopathic RF (iRF). This retrospective study concerned 50 consecutive patients with MRI-based RF diagnoses, 35 of whom also had histologically proven RF. Previous radiotherapy, abdominal or pelvic surgery or infection during the preceding 6 months, vascular aneurysm (aorta or iliac artery), presence of retroperitoneal multiple nodular masses, or enlarged lymph nodes with a diameter >15 mm constituted exclusion criteria. Patients with mRF differed from those with iRF by age, smoking habits, and follow-up duration but not by clinical manifestations, inflammatory syndrome, or renal insufficiency. MRI-documented mRF extension along the aorta, from above the renal arteries to below the aortic bifurcation, was more frequent than iRF (47% vs. 0%; p = 0.001) but less frequent between the renal arteries and the aortic bifurcation (18% vs. 50%; p = 0.04); mRF extension behind the aorta was wider than iRF (5.0 vs. 2.5 mm; p = 0.03). Neither urinary tract nor vessel involvement differed. Medial ureteral attraction was significantly less frequent in mRF than iRF (24% vs. 83%; p < 0.001), according to univariate and multivariate analyses. An algorithm based on the most discriminant criteria (RF extending from above the renal arteries to below the aortic bifurcation and the absence of medial ureteral attraction) for mRF diagnosis had 82% sensitivity and 83% specificity. When applied to the 15 iRF patients without histologic data, specificity was 73%. This mRF decision tree, consisting of the 2 most discriminant MRI criteria, could be used as a supplementary argument to support RF biopsy.

Idiopathic retroperitoneal fibrosis mimicking malignant lymphoma

We present a case of atypical idiopathic retroperitoneal fibrosis (iRPF) presenting as a large pelvic tumor, for which it proved difficult to exclude T-cell malignant lymphoma. Histopathological examination of biopsy material showed collagenous tissue and fat with an exuberant and predominant T-cell infiltrate, largely consisting of CD4(+) cells expressing the IL-2 receptor-α chain (CD25). Focal plasma cells were negative for the immunoglobulin G4 (IgG4) isotype. T-cell receptor gene rearrangement (TRGR) pattern showed a Gaussian distribution, in keeping with a polyclonal T-cell population. Awareness of the sometimes exuberant and predominant T-cell infiltrate in iRPF should lead to earlier consideration of this disorder. This is particularly the case where there is an atypically localized and/or extensive mass, for which early exclusion of monoclonality with TRGR may provide helpful. Immunohistochemical findings suggest that CD4(+) CD25(+) cells, which are part of a naturally occurring population of regulatory T-cells, may be involved in the pathogenesis of iRPF.

Invasive lobular carcinoma of the breast presenting as retroperitoneal fibrosis: a case report

INTRODUCTION

Invasive lobular carcinoma of the breast represents approximately 6.3% of mammary malignancies. Distant metastasis of invasive lobular carcinoma to the peritoneum or retroperitoneum has been reported fairly frequently.

CASE PRESENTATION

We report the case of a 59-year-old Caucasian-Canadian woman with invasive lobular carcinoma of the breast presenting with retroperitoneal fibrosis and bilateral ureteral obstruction. Intra-operative pathology consultation did not reveal malignancy. The diagnosis, however, was confirmed on permanent sections by histological appearance in addition to immunohistochemistry. To the best of our knowledge, this is the first reported case of invasive lobular carcinoma of the breast presenting with retroperitoneal fibrosis.

CONCLUSION

In a case of unexplained ureteric obstruction and retroperitoneal fibrosis, more comprehensive physical examination and additional ancillary studies may be warranted to rule out malignancy as an underlying etiology. This case also emphasizes that intra-operative frozen section consultation cannot always be fully relied upon to exclude a malignancy as the etiology of retroperitoneal fibrosis. Moreover, in permanent histopathology sections, immunohistochemistry testing can be of value to rule out metastatic disease where the morphology is not salient. There is a need for a thorough physical examination of patients with retroperitoneal fibrosis, including the breast and gynecological organs.

[Retroperitonal fibrosis and lymphoma in a 15-year-old boy]

Retroperitoneal fibrosis (RF) is a rare disease in children. We report the case of a 15-year-old boy who presented with a 2-month history of dorsal pain and a 2-week history of fever. The erythrocyte sedimentation rate and serum C-reactive protein value were high. Magnetic resonance imaging revealed a large heterogeneous retroperitoneal mass, suggestive of RF. Percutaneous biopsy of inguinal lymph node provided the diagnosis of anaplastic large cell lymphoma. This is the first report of RF revealing malignancy in childhood. It emphasizes that malignancy must be carefully searched for in children with unexplained RF.

Recurrence of retroperitoneal fibrosis with pancreatic involvement — the importance of imaging methods

Retroperitoneal fibrosis (RPF) is a rare disease associated with the development of chronic inflammation and fibrogenesis in the retroperitoneal space. The disease usually manifests with acute or acute over chronic renal failure and/or urosepsis. Pancreatic involvement in RPF is rare but has been described in the literature. The diagnosis of RPF is made mainly by imaging methods. Abdominal echography scan reveals the presence of an obstruction with or without inflammation; computed tomography and magnetic resonance imaging show the type and the spreading of fibrosis. Here, we report a 50-year-old female patient diagnosed with RPF during operative intervention in 2003. Initial treatment with corticosteroids and tamoxifen lead to remission. In 2007, late recurrence was observed, with tumor-like lesions over the upper, posterior, and anterior surfaces of the pancreas, spreading to intraperitoneal structures and more pronounced on the left side. Abdominal echography on day 30 showed that corticosteroid treatment lead to a decrease in the tumor-like lesions.

[Retroperitoneal fibrosis secondary to gastric neoplasia]

The retroperitoneal fibrosis is a very little frequent pathology that habitually includes the abdominal aorta and ureters. Two thirds of cases the etiology is idiopathic and in a third it is secondary to other causes as drugs, generalized infections or diseases and tumors which are considered to be responsible from 8 to 10%. The most frequent is colorectal adenocarcinoma, being anecdotal the gastric location with six described cases to date. We present a case of a patient with gastric cancer and secondary retroperitoneal fibrosis of difficult diagnosis and handling.

Clinical value of gallium-67 SPECT scintigraphy in the diagnostic and therapeutic evaluation of retroperitoneal fibrosis: a prospective study

BACKGROUND

Gallium-67 (67Ga) scintigraphy may be useful in evaluating patients with retroperitoneal fibrosis (RPF), but a systematic assessment of its value is lacking.

OBJECTIVE

Prospective evaluation of the value of 67Ga scintigraphy in assessing active RPF disease and in predicting treatment response.

METHODS

Thirty-four patients with nonmalignant RPF treated with tamoxifen underwent 67Ga scintigraphy at baseline and--if baseline gallium scan was positive--at 3 months follow-up. Gallium scans were visually scored according to pathologic 67Ga-uptake compared to normal bone marrow 67Ga-uptake. Results were correlated with other (follow-up) measurements. Value of (follow-up) 67Ga scintigraphy in predicting treatment response was also assessed.

RESULTS

Gallium scans were positive in 24 patients (71%). Mass thickness was greater in patients with positive gallium scan compared with patients with negative gallium scan (P = 0.006). Visual gallium score correlated with mass thickness (P = 0.006). Visual gallium score decreased significantly following tamoxifen treatment (P < 0.0001). Decrease in visual gallium score correlated with decreases in C-reactive protein and erythrocyte sedimentation rate (P = 0.019) and with decrease in mass thickness (P < 0.01). Positive predicting value (PPV) of positive baseline gallium scan was 0.71; PPV of negative follow-up gallium scan in patients with initial positive scan was 0.89. 67Ga scintigraphy detected extra-abdominal involvement in one patient and recurrent active disease in two symptomatic patients with normal acute-phase reactants and stable residual mass.

CONCLUSION

67Ga scintigraphy is useful in assessing (recurrent) activity of RPF disease and in evaluating treatment response in patients with initial positive gallium scan.

Combined Prednisone and Mycophenolate Mofetil Treatment for Retroperitoneal Fibrosis

PURPOSE

We determined the efficacy of a combination of corticosteroids and mycophenolate mofetil for retroperitoneal fibrosis.

MATERIALS AND METHODS

We performed a prospective observational study of the treatment of 7 patients with biopsy proven retroperitoneal fibrosis. Patients were treated with 40 mg prednisone daily with a gradual taper over 6 months. Mycophenolate mofetil was administered at a starting dose of 1,000 mg twice daily and continued for 6 months following resolution of systemic symptoms and extubation of affected ureters. Outcomes included normalization of laboratory evidence of inflammation, regression of fibrosis by computerized tomography and the ability to discontinue ureteral stents.

RESULTS

Seven patients were treated with mycophenolate mofetil and prednisone. Five of the 7 patients had bilateral ureteral obstruction and 1 had unilateral obstruction requiring ureteral stents. Baseline and followup laboratory values were C-reactive protein 8.9 and 1.3 mg/dl (p=0.07), hemoglobin 10.7 and 12.7 gm/dl (p=0.001), erythrocyte sedimentation rate 76 and 14.5 mm per hour (p=0.015) and serum creatinine 3.32 and 1.08 mg/dl (p=0.07), respectively. Six of the 7 patients had a mean 32% regression of the retroperitoneal mass on computerized tomography. Ten of the 11 obstructed ureters were free of obstruction following ureteral stent removal. The mean time to stent removal was 10.5 months. One patient had a distal ureteral stricture and continued to require decompression. There were no treatment related side affects.

CONCLUSIONS

Mycophenolate mofetil combined with prednisone was safe and efficacious in this small cohort of patients with retroperitoneal fibrosis. Larger trials are needed to confirm these results.

Long-term renal and patient outcome in idiopathic retroperitoneal fibrosis treated with prednisone

BACKGROUND

Primary medical treatment of idiopathic retroperitoneal fibrosis (RPF) increasingly is accepted. However, the optimum treatment strategy is still unclear.

STUDY DESIGN

Case series.

SETTING & PARTICIPANTS

Single tertiary care referral center. 24 patients with idiopathic RPF treated with prednisone for 1 year, if needed, with (urgent) renal drainage from June 1991 through October 2006.

OUTCOME & MEASUREMENTS

Clinical improvement, laboratory parameters, repeated computed tomographic (CT) scanning. Treatment was considered successful if the following criteria were met at the end of the 1-year treatment period: significant subjective clinical improvement, (near-)normalization of acute-phase reactants, improvement in renal function with disappearance of ureteral obstruction, and CT-documented mass regression. Recurrence is defined as need for retreatment because of return of signs and symptoms after the 1-year treatment period in patients with initial treatment success.

RESULTS

22 patients reported significant to complete resolution of symptoms after median treatment duration of 2.0 weeks (0.7 to 3.0). Follow-up showed decreases in erythrocyte sedimentation rate, C-reactive protein level (both P < 0.0001), and serum creatinine level (P = 0.0230) at 6 weeks, which persisted during the treatment period. Repeated CT scanning showed mass regression in 19 patients during the treatment period. Six patients were considered treatment failures, and there were 23 recurrences 10 months (7 to 14) after prednisone withdrawal in 13 of 18 patients with initial treatment success. At the end of follow-up (median, 55 months), 7 patients had impaired renal function; 1 patient reached end-stage renal disease. The mortality rate was 8%.

LIMITATIONS

There was no comparison with other treatments.

CONCLUSION

One-year treatment with prednisone is associated with a high rate of initial success, but a high recurrence rate. Despite frequent disease relapse, long-term renal and patient outcome was good.

Retroperitoneal Fibrosis, Today: An Updating of Knowledges on this Subjet

Retroperitoneal fibrosis (RPF) is characterized, at first, by a replacement of the normal retroperitoneal tissue by an active granulomatosis inflammation (cellular phase), and at a later stage by a fibrous scar tissue (established fibrotic phase). The aetiology of secondary RPFs includes several drugs (notably methysergide, ergotamine, pergolide, hydralazine), both chronic atherosclerotic aortitis-periaortitis and inflammatory aortic aneurisms, autoimmune diseases such as different forms of systemic vasculitis and collagen diseases, histiocytosis such as Erdheim-Chester syndrome, desmoplastic reactions to retroperitoneal malignancy carcinoid syndrome, retroperitoneal accidentally and surgically occurred traumas, abdominal radiation therapy.

On the contrary, the causes of idiopathic RPF remain uncertain; its pathogenesis is associated to immuno-mediated mechanisms. The inflammatory process can involve retroperitoneal vessels, ureters, peri- and pararenal spaces, mesenteric small intestine, duodenum, psoas muscles, and can spread to mediastinal space. Diagnosis and characterization of the polyphase inflammatory evolution require integrated approaches including laboratory tests, morpho-functional imaging and, sometimes, histopathologic assessment. In the early stages, the management of RPF ranges from the removal of identifiable etiologic agents to the interfering with the inflammatory immuno-mediated process by means of several drugs. Unfortunately, many effective immunosuppressive drugs induce adverse reactions unrelated to their specific immunosuppressive action; this is the reason why the biopharmacology research today is struggling towards the identification of molecular targets having their expression restricted to immune cells and/or cytokines. Moreover, the progression of atheromatous aortitis to RPF could be prevented by statins which are able to interfere with the inflammatory pathway as well as to induce the well-known reduction in the levels of atherogenic lipoproteins. In the late established fibrotic stage, either open surgery or endourologic, laparoscopic procedures are performed; nevertheless neoadiuvant and adiuvant corticosteroid-immunosuppressive treatments are mandatory in order to avoid any relapse of the disease.

Retroperitoneal fibrosis

Retroperitoneal fibrosis encompasses a range of diseases characterised by the presence of a fibro-inflammatory tissue, which usually surrounds the abdominal aorta and the iliac arteries and extends into the retroperitoneum to envelop neighbouring structures--eg, ureters. Retroperitoneal fibrosis is generally idiopathic, but can also be secondary to the use of certain drugs, malignant diseases, infections, and surgery. Idiopathic disease was thought to result from a local inflammatory reaction to antigens in the atherosclerotic plaques of the abdominal aorta, but clinicolaboratory findings--namely, the presence of constitutional symptoms and the high concentrations of acute-phase reactants--and the frequent association of the disease with autoimmune diseases that involve other organs suggest that it might be a manifestation of a systemic autoimmune or inflammatory disease. Steroids are normally used to treat idiopathic retroperitoneal fibrosis, although other options--eg, immunosuppressants, tamoxifen--are available. The outlook is usually good, but, if not appropriately diagnosed or treated, the disease can cause severe complications, such as end-stage renal failure. Here, we review the different aspects of retroperitoneal fibrosis, focusing on idiopathic retroperitoneal fibrosis and on the differential diagnosis associated with the secondary forms.