Recurrent retroperitoneal tumors

　　1. Etiology

　　Primary retroperitoneal tumors are more prone to recurrence after surgery, and the main reason is:

　　1. Characteristics and nature of the primary tumor:The characteristics and nature of the primary tumor are the primary cause of postoperative recurrence. According to statistics, liposarcoma is the most common in cases of recurrent retroperitoneal primary tumors, followed by leiomyosarcoma, malignant fibrous histiocytoma, neurofibrosarcoma, and malignant mesothelioma, etc. The time of tumor recurrence after surgery varies from 1 to 10 years, with a higher malignancy often recurrence within 2 years after surgery.

　　2. Incomplete resection during the first surgery:The recurrence of tumors is not only due to the characteristics and nature of the primary tumor itself, but also mainly determined by the thoroughness of the initial tumor resection. The retroperitoneal space is a potential cavity between the parietal peritoneum and the transversalis fascia, with the lateral wall formed by the transversus abdominis and iliacopsoas muscles on both sides. The posterior part is formed by the quadratus lumborum and transversus abdominis tendons. The anterior part has important hollow visceras and solid organs as well as pelvic organs; the abdominal aorta, inferior vena cava, and iliac vessels pass through it; the main organs of the urinary and reproductive systems, such as the kidneys, ureters, testicles, and ovarian vessels, are located in it; and the nervous and lymphatic networks are interlaced and densely distributed. Tumors in this region are not easily detected early, and when diagnosed, the tumors are often large and may encircle or invade important organs. During the initial surgery, it is difficult to resect the tumor tissue completely to avoid damage to certain important organs, and the remaining tumor tissue is one of the important reasons for recurrence after surgery.

　　3. Molecular genetic characteristics of tumors:Recent studies have shown that most soft tissue tumors have non-random clonal chromosomal abnormalities and (or) gene mutations and amplifications, such as most lipomas, which have different chromosomal abnormalities regardless of their benign or malignant nature. Due to the obvious molecular genetic characteristics of certain tumors, their recurrence and multifocality are inevitable phenomena.

　　4. Insensitive to chemotherapy and radiotherapy:Except for lymphosarcoma and retroperitoneal tumors of reproductive origin, most primary retroperitoneal tumors are not sensitive to chemotherapy.

　　Secondly, pathogenesis

　　Clinical observations suggest that the recurrent sites of retroperitoneal tumors are often at the base of the primary tumor, and their growth patterns are similar to those of the primary tumor. Malignant recurrent retroperitoneal tumors are more likely to invade multiple organs or large blood vessels. After recurrence, they still mainly grow expansively, and the largest diameter of the tumor is often more than 10 cm, and pseudocapsules are still formed, with rare distant metastasis; the pathological type is the same as that of the primary tumor. However, the degree of malignancy gradually increases with each recurrence, the growth rate significantly accelerates, and the interval between recurrences becomes shorter. Close follow-up should be conducted after the resection of the primary tumor.

　　1. Anemia:Tumor bleeding or rapid growth of retroperitoneal tumors in children may lead to decreased hemoglobin levels.

　　2. Hypokalemia:When the tumor is large and compresses or displaces the gastrointestinal tract, patients may experience anorexia, nausea, vomiting, diarrhea, etc., leading to significant potassium loss and insufficient replenishment, resulting in decreased blood potassium levels and electrolyte disorders in serum.

　　3. Acute peritonitis:When the tumor ruptures, the stimulation of blood to the peritoneum may cause symptoms and signs of acute peritonitis such as abdominal pain, muscular tension, tenderness, and rebound pain.

　　4. Hypovolemic shock:Massive bleeding may occur if the tumor ruptures or invades large blood vessels, leading to hypovolemic shock.

　　1. Abdominal mass:After the first operation, if an abdominal mass appears again, the location of the tumor is the same as or similar to that of the primary retroperitoneal tumor. When examining the tumor with the knees and elbows in a kneeling-lotus position, the tumor does not hang forward and there is a tympanic percussion on the anterior abdominal wall. However, when the tumor is large, the anterior abdominal wall also shows a dull sound on percussion. The percussion sound of retroperitoneal tumor area is often the sound of normal intestinal loops. A few patients have ascites, which is often not percussible, and the intestinal peristalsis sound is normal or slightly increased.

　　2. Abdominal distension:As the tumor grows, patients gradually develop a feeling of abdominal distension. Due to the displacement of the gastrointestinal tract, it is often tympanic when percussing above or on one side of the tumor, and the intestinal peristalsis sound is normal or slightly increased.

　　3. Abdominal pain:As the course of the disease progresses, a sense of weight, dull or tingling pain, or severe pain may occur in the abdomen due to the erosion of adjacent organs or nerves by malignant tumors. Back pain may occur if the tumor invades the posterior abdominal wall, and pain or numbness in one or both lower limbs may occur if the lumbar plexus is invaded.

　　6. Manifestations of adjacent organ involvement:Symptoms such as nausea, vomiting, diarrhea, constipation; internal hemorrhoids, varicose veins around the umbilicus; jaundice; frequent urination, urgency, difficulty in urination; lower limb edema, varicose veins of the spermatic cord, etc.

　　Postoperative follow-up of retroperitoneal tumors should be emphasized, and awareness of retroperitoneal tumors should be improved.

　　It is very important to schedule postoperative follow-up reviews. Being able to detect recurrent small lesions in time can help gain time and initiative for a second operation, which is crucial for improving the survival rate and prognosis of patients. In order to detect recurrent cases early, for patients with complete resection of the primary tumor, the follow-up interval should not exceed 3 months each time. For patients with uncertain resection margins or residual tumors, the follow-up interval should be shortened. When the volume of the recurrent tumor is relatively small, the opportunity for a second complete resection increases significantly.

　　I. Laboratory examination:

　　1. Blood routine:

　　(1) Hemoglobin: When the central necrosis, hemorrhage of malignant tumors, or when the retroperitoneal tumors in children grow rapidly, there may be a decrease in hemoglobin.

　　(2) White blood cell count: There may be an increase in the total amount of white blood cells when retroperitoneal tumors necrotize or secondary infection occurs.

　　2. Histopathological examination:Before surgery, it should be possible to make a diagnosis with other methods as much as possible. If necessary, laparotomy or laparoscopic surgery can be performed to take a biopsy for pathological examination.

　　II. Imaging Examination:

　　1. Ultrasound examination:It is the first choice for postoperative routine follow-up examination, and it should start within 3 months after the first operation. Through ultrasound, it can understand the location, size, number, and relationship with surrounding organs of the recurrent tumor, and can judge whether the tumor is cystic or solid, and can differentiate whether it is derived from retroperitoneal or peritoneal cavity, and understand whether it has involved other organs.

　　2. CT scan:CT scan can clearly show the location, size, shape, and relationship with surrounding organs and blood vessels of the tumor, providing the main basis for preoperative diagnosis and reoperation. The accuracy rate of positioning can reach 80% to 90%, and spiral CT can scan from multiple angles and multiple planes, and reconstruct the image in two stages. It can clearly show the aorta and its branches, the course of portal vein, the shape, number, and relationship with adjacent organs of recurrent tumors, lymph node metastasis foci, and other tissues, with higher resolution than ordinary CT.

　　3. MRI:Can show soft tissues well, can be examined in multiple directions, and can accurately understand the relationship between the tumor and blood vessels. However, because the cost of the examination is expensive, it can be used as the diagnosis of special difficult cases.

　　4. Digital subtraction angiography:Can understand the invasion of main blood vessels and the main blood supply arteries of the tumor, which is helpful for the treatment of the main blood vessels of the tumor during surgery. During the performance of digital subtraction angiography, if it is found that the tumor has a main nutrient blood vessel, interventional therapy and vascular embolization can be performed at the same time, so that the tumor can be necrotic, shrink, and easy for reoperation.

　　5. Intravenous pyelography and gastrointestinal contrast study:Can understand the situation of ureteral and gastrointestinal invasion, and prepare for combined organ resection.

　　I. Postoperative Dietary Formula for Recurrent Retroperitoneal Tumor

　　1. Red Date and Brown Sugar Stewed Pumpkin

　　[Ingredients] 500g fresh pumpkin, 20g red dates, an appropriate amount of brown sugar.

　　[Method] Peel the pumpkin, cut into small cubes, add red dates and brown sugar, cook with water until done.

　　[Usage] Eat as a side dish, it is better to eat on an empty stomach.

　　[Indications] Suitable for those with postoperative deficiency of Qi and blood, and weak physique.

　　2. Black Sesame Bean Milk

　　[Ingredients] 30g black sesame seeds, 40g soybean powder.

　　[Method] Roast black sesame seeds over low heat until cooked, grind into fine powder and set aside. Put soybean powder in a pot, add an appropriate amount of water, stir to make a thin paste, soak for 30 minutes, simmer over low heat until boiling, filter the soy milk with a cheesecloth, add it back to the pot, simmer over low heat until boiling again, add black sesame powder, mix well and it is ready.

　　[Usage] Take in the morning and evening, and you can add brown sugar as needed.

　　[Applicable] Especially suitable for patients with deficiency of both Qi and blood after surgery, and deficiency of liver blood.

　　3. Astragalus perch soup

　　[Ingredients] 1 perch (200g), 30g of Astragalus, 30g of Chinese yam, 6g of tangerine peel, 4 slices of ginger.

　　[Preparation] Clean and cut the perch into pieces. Wash Astragalus, Chinese yam, and tangerine peel, and put all the ingredients into the pot. Add an appropriate amount of water, boil it over high heat, and then simmer over low heat for 1 hour.

　　[Usage] Drink the soup and eat the meat.

　　[Applicable] Invigorate the spleen and Qi, harmonize the stomach and middle energizer, especially suitable for the recovery of physical fitness after surgery.

　　4. Jujube stewed rabbit meat

　　[Ingredients] 60g of jujube, 250g of rabbit meat.

　　[Preparation] Wash the rabbit meat clean, put it into a pot of boiling water to blanch and then take it out and cut it into small pieces. Put the pieces of jujube in the pot and add an appropriate amount of water. Boil it over high heat, add cooking wine, and then simmer over low heat for 40 minutes. After the rabbit meat is cooked, add scallion, ginger, salt, monosodium glutamate, and five-spice powder and mix well. Boil it again and add sesame oil to finish.

　　[Usage] Take as a dish with meals, eat freely.

　　[Applicable] Tonify both Qi and blood, restore physical and mental strength after surgery.

　　Two, what foods are good for recurrent retroperitoneal tumors

　　1. Generally, patients can eat liquid food 6 to 12 hours after surgery, such as rice porridge, thin lotus root powder, vegetable juice, fruit juice, etc., and soft food or regular food on the second day, such as soft rice, noodles, egg pudding, chopped and cooked vegetables and meat, etc., with a diet rich in nutrition, easy to digest, and light in taste as the main.

　　2. In terms of diet, you can eat more nutritious foods. Eat more coarse fiber foods, such as chives, celery, cabbage, coarse grains, beans, bamboo shoots, and various fruits, etc.

　　3. Keep the bowels smooth, and you can use jellyfish, bitter melon, sweet potatoes, etc.

　　Three, what foods should not be eaten by recurrent retroperitoneal tumors

　　1. After surgery, avoid eating foods that can cause intestinal bloating, such as milk, soy milk, and eggs.

　　2. Avoid smoking, alcohol, greasy, fried, moldy, and salted foods.

　　3. Avoid spicy foods such as garlic and mustard greens.

　　Surgical treatment:

　　Postoperative recurrence of retroperitoneal tumors is mostly local recurrence, rarely distant metastasis, which provides conditions for reoperation. Karakousis et al. reported 33 cases of recurrent retroperitoneal soft tissue sarcoma, 29 of whom underwent complete resection again, with a 5-year survival rate of 57%. Chinese scholars have also reported 33 cases of recurrent retroperitoneal sarcoma, with 17 cases undergoing complete resection again, and a 5-year survival rate of 42%. The reoperation and surgical outcomes of recurrent retroperitoneal tumors are quite good, and some cases require multiple operations to achieve the goal of cure. If the tumor has invaded adjacent organs during the reoperation, organ resection should be combined as long as it does not affect the function; for recurrent tumors that cannot be completely resected, maximum partial resection should be performed to achieve the goal of tumor reduction. This not only relieves the pressure of the tumor on the organs but also creates conditions for other auxiliary treatments after surgery.

　　Injury to large blood vessels and massive bleeding during reoperation for recurrent tumors are often encountered difficult problems. If the tumor originates from or invades a large blood vessel,强行剥离 may damage the vessel and cause massive bleeding. If the tumor tissue surrounding the blood vessel is not resected, it may lead to the recurrence of the tumor after surgery. Therefore, when reoperating on retroperitoneal tumors, more consideration should be given to the reconstruction of blood vessels. If the tumor invades the inferior vena cava, after transection or ligation below the renal vein, blood can flow back through the lumbar venous plexus and other collateral vessels, and it is not necessary to perform vascular transplantation. To prevent postoperative lower limb edema, it is best to perform artificial vascular transplantation after the inferior vena cava is excised. After excision of the abdominal aorta segment, artificial vascular transplantation is required, and the excision length of the abdominal aorta should not exceed 3 pairs of lumbar arteries, otherwise, paraplegia may occur due to spinal cord ischemia. When the iliac vessels are excised more than 3 cm, vascular transplantation is required, and when less than 3 cm, it can be performed by end-to-end anastomosis after free mobilization. To reduce bleeding during the excision of retroperitoneal tumors at the pelvic floor, it is advisable to ligate both iliac internal arteries first, which will not affect the blood supply of pelvic organs.

　　Due to changes in the local anatomical relationship of the recurrent retroperitoneal tumor, the tumor is large, located deeply, the operation space is small, and it is easy to injure the great retroperitoneal blood vessels, a large amount of bleeding may occur during reoperation. There should be a full estimate of the amount of bleeding and sufficient blood reserve to ensure the completion of the operation. If conditions permit, a digital subtraction angiography should be performed before the operation to find the main blood supply artery for embolization therapy, which can reduce bleeding during the operation. However, due to the high malignancy and rich blood supply of the tumor, there are often multiple blood supply arteries, and the embolization hemostasis effect is often not satisfactory.