tumores retroperitoneales
TRANSCRIPT
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Tumores retroperitoneales
Guillermo Orrico Velázquez.Residente de tercer año Urología.07-03-2016. León, Guanajuato.Unidad Medica de Alta Especialidad. Centro Medico Nacional del Bajío.
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RETROPERITONEO LIMITES ANATÓMICOS:
◦ Pared abdominal posterior
◦ fascia toracolumbar (3 capas)
◦ musculo sacroespinoso
◦ musculo cuadrado lumbar.
◦ Músculos de la pared anterior
◦ Peritoneo
◦ Diafragma
◦ Se continua con las estructuras pélvicas
Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urology. Elsevier Saunders. 11th edition, 2016. Chapter 33 .
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RETROPERITONEO LIMITES ANATÓMICOS:
◦ Pared abdominal posterior
◦ fascia toracolumbar (3 capas)
◦ musculo sacroespinoso
◦ musculo cuadrado lumbar.
◦ Músculo transverso
◦ Peritoneo
◦ Diafragma
◦ Se continua con las estructuras pélvicas extraperitoneales.
Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urology. Elsevier Saunders. 11th edition, 2016. Chapter 33 .
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RETROPERITONEO
Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urology. Elsevier Saunders. 11th edition, 2016. Chapter 33 .
![Page 5: Tumores retroperitoneales](https://reader035.vdocuments.co/reader035/viewer/2022062302/58ab34a11a28abb64d8b595f/html5/thumbnails/5.jpg)
RETROPERITONEO
Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urology. Elsevier Saunders. 11th edition, 2016. Chapter 33 .
![Page 6: Tumores retroperitoneales](https://reader035.vdocuments.co/reader035/viewer/2022062302/58ab34a11a28abb64d8b595f/html5/thumbnails/6.jpg)
RETROPERITONEO
Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urology. Elsevier Saunders. 11th edition, 2016. Chapter 33 .
![Page 7: Tumores retroperitoneales](https://reader035.vdocuments.co/reader035/viewer/2022062302/58ab34a11a28abb64d8b595f/html5/thumbnails/7.jpg)
RETROPERITONEO
Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urology. Elsevier Saunders. 11th edition, 2016. Chapter 33 .
![Page 8: Tumores retroperitoneales](https://reader035.vdocuments.co/reader035/viewer/2022062302/58ab34a11a28abb64d8b595f/html5/thumbnails/8.jpg)
RETROPERITONEO
Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urology. Elsevier Saunders. 11th edition, 2016. Chapter 33 .
![Page 9: Tumores retroperitoneales](https://reader035.vdocuments.co/reader035/viewer/2022062302/58ab34a11a28abb64d8b595f/html5/thumbnails/9.jpg)
RETROPERITONEO
Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urology. Elsevier Saunders. 11th edition, 2016. Chapter 33 .
![Page 10: Tumores retroperitoneales](https://reader035.vdocuments.co/reader035/viewer/2022062302/58ab34a11a28abb64d8b595f/html5/thumbnails/10.jpg)
RETROPERITONEO
Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urology. Elsevier Saunders. 11th edition, 2016. Chapter 33 .
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RETROPERITONEO
Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urology. Elsevier Saunders. 11th edition, 2016. Chapter 33 .
![Page 12: Tumores retroperitoneales](https://reader035.vdocuments.co/reader035/viewer/2022062302/58ab34a11a28abb64d8b595f/html5/thumbnails/12.jpg)
RETROPERITONEO
Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urology. Elsevier Saunders. 11th edition, 2016. Chapter 33 .
![Page 13: Tumores retroperitoneales](https://reader035.vdocuments.co/reader035/viewer/2022062302/58ab34a11a28abb64d8b595f/html5/thumbnails/13.jpg)
RETROPERITONEO
Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urology. Elsevier Saunders. 11th edition, 2016. Chapter 33 .
![Page 14: Tumores retroperitoneales](https://reader035.vdocuments.co/reader035/viewer/2022062302/58ab34a11a28abb64d8b595f/html5/thumbnails/14.jpg)
RETROPERITONEO
Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urology. Elsevier Saunders. 11th edition, 2016. Chapter 33 .
![Page 15: Tumores retroperitoneales](https://reader035.vdocuments.co/reader035/viewer/2022062302/58ab34a11a28abb64d8b595f/html5/thumbnails/15.jpg)
TUMORES RETROPERITONEALES Tumores retroperitoneales primarios
•Grupos de neoplasias raras
•Surgen en el retroperitoneo y la pelvis
•Derivadas de mesénquima
•No propios del tracto urogenital urólogo parte fundamental en el diagnostico y tratamiento
Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urology. Elsevier Saunders. 11th edition, 2016. Chapter 59 .
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TUMORES RETROPERITONEALES Tumores retroperitoneales primarios
•Benignos o malignos
•Tendencia a crecimiento extensivo
•Invasión local a órganos vecinos
•Propensión a la diseminación hematógena pulmones e hígado
Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urology. Elsevier Saunders. 11th edition, 2016. Chapter 59 .
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TUMORES RETROPERITONEALES Tumores retroperitoneales primarios
•Epidemiologia
•Se desconoce su incidencia real
•2013 12 020 casos de sarcomas en EUA
•4740 muertes específicas de cáncer en la población general
•Los sarcomas de tejidos blandos constituyen el 1% en
adultos y el 15% en niños, de todas las neoplasias
Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urology. Elsevier Saunders. 11th edition, 2016. Chapter 59 .
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TUMORES RETROPERITONEALES Tumores retroperitoneales primarios
•Epidemiologia
•Sexta década de la vida
•Hombres sexo mas afectado
Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urology. Elsevier Saunders. 11th edition, 2016. Chapter 59 .
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TUMORES RETROPERITONEALES Tumores retroperitoneales primarios
•Epidemiologia
•60% de los sarcomas originados por las extremidades
•20% en el tronco
•15% en el retroperitoneo
•5% a 10% de la cabeza y el cuello
Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urology. Elsevier Saunders. 11th edition, 2016. Chapter 59 .
Benignos
Malignos
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TUMORES RETROPERITONEALES Tumores retroperitoneales primarios
•Epidemiologia
•50 % mayores de 15 cm al momento del diagnostico
•Sarcomas retroperitoneales 80 %
• Liposarcoma
• Leiomiosarcoma
• Histiocioma fibroso maligno
Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urology. Elsevier Saunders. 11th edition, 2016. Chapter 59 .
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TUMORES RETROPERITONEALES Tumores retroperitoneales primarios
Factores de riesgo
•Exposición a la radiación
•Exposición a dioxinas clorobencenos grasas animales
•Predisposición genética síndrome de Gardner
•Inmunosupresión
•Infecciones virales
Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urology. Elsevier Saunders. 11th edition, 2016. Chapter 59 .
Poliposis de colon Osteomas
Lipomas Quistes epidérmicos
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TUMORES RETROPERITONEALES Tumores retroperitoneales primarios
Patogénesis
•Progenitor celular pluripotente
•Células madre mesenquimales nichos
•Tejido heterotópico
•Recambio celular lento y menor apoptosis
Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urology. Elsevier Saunders. 11th edition, 2016. Chapter 59 .
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TUMORES RETROPERITONEALES Tumores retroperitoneales primarios
Dunnick R., Sandler C., Newhouse J. Textbook of uroradiology. 5th edition,2013, The retroperitoneum, Chapter 5.
Benignos
Lipomas
Lipoblastomas
Neurofibroma
Linfangioma
Mielolipoma
Teratoma
Feocromocitoma extra adrenal
Paraganglioma
Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urology. Elsevier Saunders. 11th edition, 2016. Chapter 59 .
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TUMORES RETROPERITONEALES Tumores retroperitoneales primarios benignos
•Menos comunes
•Lesiones pequeñas
•Circunscritas
•Células morfología conservada
•Vacuolas citoplásmica o en patrón fusiforme
Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urology. Elsevier Saunders. 11th edition, 2016. Chapter 59 .
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TUMORES RETROPERITONEALES Tumores retroperitoneales primarios benignos
•Lipoma
•Densidad grasa normal
•Homogéneo
•Sin septos o nodulaciones
Dunnick R., Sandler C., Newhouse J. Textbook of uroradiology. 5th edition,2013, The retroperitoneum, Chapter 5.Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urology. Elsevier Saunders. 11th
edition, 2016. Chapter 59 .
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TUMORES RETROPERITONEALES Tumores retroperitoneales primarios benignos
•Lipoblastoma
•Tejido adiposo fetal
•Lesiones únicas y superficiales
•Mas habituales en extremidades
•Población pediátrica
Dunnick R., Sandler C., Newhouse J. Textbook of uroradiology. 5th edition,2013, The retroperitoneum, Chapter 5.Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urology. Elsevier Saunders. 11th
edition, 2016. Chapter 59 .
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TUMORES RETROPERITONEALES Tumores retroperitoneales primarios benignos
Tumores de las vainas neuronales
•Neurofibromas
•Neurilenoma
Dunnick R., Sandler C., Newhouse J. Textbook of uroradiology. 5th edition,2013, The retroperitoneum, Chapter 5.
Región paraespinal del retroperitoneo
Degeneración quística
20 25 UH
Neurofibromatosis tipo I
Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urology. Elsevier Saunders. 11th edition, 2016. Chapter 59 .
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TUMORES RETROPERITONEALES Tumores retroperitoneales primarios benignos
Tumores de las vainas neuronales
Dunnick R., Sandler C., Newhouse J. Textbook of uroradiology. 5th edition,2013, The retroperitoneum, Chapter 5.Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urology. Elsevier Saunders. 11th
edition, 2016. Chapter 59 .
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TUMORES RETROPERITONEALES Tumores retroperitoneales primarios benignos
Teratoma
•10% de los tumores del retroperitoneo
•6 meses- adolescencia
•Mujeres:Hombres 10 : 1
Dunnick R., Sandler C., Newhouse J. Textbook of uroradiology. 5th edition,2013, The retroperitoneum, Chapter 5.
Lesiones solidas o quisticas
Complejas
Densidad grasa Niveles líquidos Calcificaciones
Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urology. Elsevier Saunders. 11th edition, 2016. Chapter 59 .
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TUMORES RETROPERITONEALES Tumores retroperitoneales primarios benignos
Teratoma
Dunnick R., Sandler C., Newhouse J. Textbook of uroradiology. 5th edition,2013, The retroperitoneum, Chapter 5.Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urology. Elsevier Saunders. 11th
edition, 2016. Chapter 59 .
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TUMORES RETROPERITONEALES Tumores retroperitoneales primarios
Dunnick R., Sandler C., Newhouse J. Textbook of uroradiology. 5th edition,2013, The retroperitoneum, Chapter 5.Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urology. Elsevier Saunders. 11th
edition, 2016. Chapter 59 .
Malignos
Liposarcoma
Leiomiosarcoma
Histiocitoma maligno
Tumor neuroectodermico primario
Fibrosarcoma
Sarcoma sinovial
Angiosarcoma
Linfangiosarcoma
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TUMORES RETROPERITONEALES Tumores retroperitoneales primarios malignos
Liposarcoma
•Neoplasia maligna primaria retroperitoneal mas común
• Bien diferenciado
• Mixoide
• Células redondas
• Desdiferenciado
• Pleomórfico
Dunnick R., Sandler C., Newhouse J. Textbook of uroradiology. 5th edition,2013, The retroperitoneum, Chapter 5.Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urology. Elsevier Saunders. 11th
edition, 2016. Chapter 59 .
Bajo grado
Alto grado
1962 Enzinger
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TUMORES RETROPERITONEALES Tumores retroperitoneales primarios malignos
Liposarcoma
•Edad de 50-70 años
•Densidad grasa y de tejidos blandos
Dunnick R., Sandler C., Newhouse J. Textbook of uroradiology. 5th edition,2013, The retroperitoneum, Chapter 5.Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urology. Elsevier Saunders. 11th
edition, 2016. Chapter 59 .
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TUMORES RETROPERITONEALES Tumores retroperitoneales primarios malignos
Leiomiosarcomas
•Poco común
•Mas común en mujeres que en hombres 3:1
•Septima década de la vida
Dunnick R., Sandler C., Newhouse J. Textbook of uroradiology. 5th edition,2013, The retroperitoneum, Chapter 5.Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urology. Elsevier Saunders. 11th
edition, 2016. Chapter 59 .
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TUMORES RETROPERITONEALES Tumores retroperitoneales primarios malignos
Leiomiosarcomas
•Degeneración quística y necrosis
•Gran tamaño
•Núcleos con forma de cigarro
Dunnick R., Sandler C., Newhouse J. Textbook of uroradiology. 5th edition,2013, The retroperitoneum, Chapter 5.Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urology. Elsevier Saunders. 11th
edition, 2016. Chapter 59 .
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TUMORES RETROPERITONEALES Tumores retroperitoneales primarios malignos
Leiomiosarcomas
•Derivada del musculo liso de las pardes vasculares
• Componente intra y extravascular
• Por arriba de la vena renal y debajo de la vena hepática
Dunnick R., Sandler C., Newhouse J. Textbook of uroradiology. 5th edition,2013, The retroperitoneum, Chapter 5.Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urology. Elsevier Saunders. 11th
edition, 2016. Chapter 59 .
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TUMORES RETROPERITONEALES Tumores retroperitoneales primarios malignos
Leiomiosarcomas
Dunnick R., Sandler C., Newhouse J. Textbook of uroradiology. 5th edition,2013, The retroperitoneum, Chapter 5.
T 1 T 2
Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urology. Elsevier Saunders. 11th edition, 2016. Chapter 59 .
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TUMORES RETROPERITONEALES Tumores retroperitoneales primarios malignos
Estadificación
Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urology. Elsevier Saunders. 11th edition, 2016. Chapter 59 .
TNMT0 Tumor no demostrable
T1 Tumor < 5 cm en su diámetro máximo
T2 Tumor > 5 cm en su diámetro máximo
T3 Invasión macroscópica del tumor a estructuras vecinas
N0 Sin nódulos
N1 Nódulos regionales positivos
M0 Sin metástasis a distancia
M1 Metástasis presente
TNMR0 Tumor completamente resecado con márgenes
quirúrgicos negativos
R1 Tumor residual microscópico, márgenes quirúrgicos positivos
R2 Tumor residual macroscópicamente
R3 Diseminación tumoral durante la resección
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TUMORES RETROPERITONEALES Tumores retroperitoneales primarios malignos
Factores pronósticos
•Invasión tumoral
•Grado histológico
•Índice mitótico 10 HPF
•Necrosis
Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urology. Elsevier Saunders. 11th edition, 2016. Chapter 59 .
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TUMORES RETROPERITONEALES Tumores retroperitoneales primarios malignos
•Presentación clínica
•Hallazgo en estudio de imagen
•Síntomas
• Masa abdominal 80 %
• Síntomas constitucionales 30 %
Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urology. Elsevier Saunders. 11th edition, 2016. Chapter 59 .
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TUMORES RETROPERITONEALES Tumores retroperitoneales primarios malignos
•Biopsia
•Guiada por IRM, TC o USG
•Retropetitoneal
•No transperitoneal
•Aguja 14 – 16 g
•No se recomienda BAAF
Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urology. Elsevier Saunders. 11th edition, 2016. Chapter 59 .
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TUMORES RETROPERITONEALES Tumores retroperitoneales primarios malignos
•Indicaciones de biopsia
•sospecha de linfoma
•Tumor resecable *
•Tumor metastasico guía de QT
Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urology. Elsevier Saunders. 11th edition, 2016. Chapter 59 .
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TUMORES RETROPERITONEALES Tumores retroperitoneales primarios malignos
•Tratamiento
•Resección del tumor tratamiento primario
•R0 supervivencia libre de recurrencia de 80 % a 5 años
Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urology. Elsevier Saunders. 11th edition, 2016. Chapter 59 .
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TUMORES RETROPERITONEALES Tumores retroperitoneales primarios malignos
•Tratamiento
•Resección del tumor
•Involucro de órganos contiguos
•Colocación pre quirúrgica de Stents ureterales
•Resección de órganos comprometidos
•Remplazo vascular
Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urology. Elsevier Saunders. 11th edition, 2016. Chapter 59 .
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TUMORES RETROPERITONEALES
Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urology. Elsevier Saunders. 11th edition, 2016. Chapter 59 .NCCN Clinical Practice Guidelines in Oncology. Guidelines for Soft Tissue Sarcoma V.1.2015.
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TUMORES RETROPERITONEALES
Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urology. Elsevier Saunders. 11th edition, 2016. Chapter 59 .NCCN Clinical Practice Guidelines in Oncology. Guidelines for Soft Tissue Sarcoma V.1.2015.
RT preoperatoria
RT preoperatoria 12.5 Gy
No brinda resultados superiores que la cirugía sola
Mejora la técnica quirúrgica
Empeora la cicatrización 6 semanas
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TUMORES RETROPERITONEALES
Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urology. Elsevier Saunders. 11th edition, 2016. Chapter 59 .NCCN Clinical Practice Guidelines in Oncology. Guidelines for Soft Tissue Sarcoma V.1.2015.
RT posoperatoria 15 Gy
Mejor control local con márgenes quirúrgicos
Recurrencia local a 5 años 9%
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TUMORES RETROPERITONEALES
Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urology. Elsevier Saunders. 11th edition, 2016. Chapter 59 .NCCN Clinical Practice Guidelines in Oncology. Guidelines for Soft Tissue Sarcoma V.1.2015.
![Page 49: Tumores retroperitoneales](https://reader035.vdocuments.co/reader035/viewer/2022062302/58ab34a11a28abb64d8b595f/html5/thumbnails/49.jpg)
TUMORES RETROPERITONEALES Quimioterapia neoadyuvante
•Tumores de alto grado o > 10 cm
•Cirugía sola vs QT neoadyuvante
•Supervivencia libre de enfermedad 52% v 56%
Supervivencia global 64% vs 65%
Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urology. Elsevier Saunders. 11th edition, 2016. Chapter 59 .
![Page 50: Tumores retroperitoneales](https://reader035.vdocuments.co/reader035/viewer/2022062302/58ab34a11a28abb64d8b595f/html5/thumbnails/50.jpg)
Tumores retroperitoneales
Guillermo Orrico Velázquez.Residente de tercer año Urología.07-03-2016. León, Guanajuato.Unidad Medica de Alta Especialidad. Centro Medico Nacional del Bajío.