MS General Surgery Exam - Case Presentation: Mass per Abdomen

CASE PRESENTATION

CHIEF COMPLAINT

HISTORY OF PRESENT ILLNESS

PAST HISTORY

• Medical: Hypertension (5 years), on amlodipine
• Surgical: Nil
• Family History: Father died of "stomach cancer" - type unknown
• Personal/Social: Smoker (30 pack-years), moderate alcohol use, sedentary occupation

REVIEW OF SYSTEMS

• Haematuria: Yes (2 episodes, painless)
• Flank pain: Yes (right, dull, constant)
• Weight loss: Yes (6 kg/3 months)
• Bone pain: None
• Cough / haemoptysis: None
• Night sweats: Yes (mild)
• Lower limb swelling: None

PHYSICAL EXAMINATION

• Ballotability - positive
• Can get above the mass - yes (differentiates from liver)
• Band of colonic resonance - present (bowel loops anterior to kidney)
• Moves with respiration - yes
• No herniation to the loin (unlike perinephric abscess)

DIFFERENTIAL DIAGNOSIS

INVESTIGATIONS

Bedside / Routine

• Urine dipstick: Blood +++ on dipstick
• Urine microscopy: >50 RBCs/hpf (no casts, no WBCs)
• Urine cytology: Sent

Haematological

Biochemical

Imaging

• 8.2 x 7.1 cm echogenic mass in the right kidney, upper pole
• Cortical distortion present
• No renal vein/IVC involvement seen
• Contralateral kidney normal
• No ascites, no para-aortic lymphadenopathy

• Enhancing solid mass (enhancement >15 HU post-contrast = diagnostic of RCC)
• Measure maximum diameter, extent of local invasion
• Assess renal vein and IVC for tumour thrombus
• Assess Gerota's fascia, perinephric fat, adrenal gland
• Lymph node assessment (hilar, para-aortic)
• Contralateral renal assessment

• Rule out pulmonary metastases ("cannon ball" secondaries)
• Baseline pre-operative

STAGING (AJCC TNM 8th Edition)

PARANEOPLASTIC SYNDROMES OF RCC

MANAGEMENT

Pre-Operative Assessment

• Fitness for anaesthesia (cardiac, pulmonary)
• Contralateral renal function (GFR, DMSA/MAG-3 scan if required)
• Blood group and crossmatch (2 units PRBC)
• Correct hypertension, anaemia, and hypercalcaemia
• DVT prophylaxis planning

Surgical Management (Curative Intent)

• Removal of kidney, Gerota's fascia, perinephric fat, ipsilateral adrenal (only if involved)
• Approach: Open (flank/transperitoneal/retroperitoneal) or Laparoscopic/Robotic
• Adrenal gland is no longer routinely removed unless directly involved
• Regional lymphadenectomy for staging

• Preferred for T1 tumours (<7 cm), solitary kidney, bilateral tumours, CKD patients
• Comparable oncological outcomes to radical nephrectomy for T1a

• Requires cardiopulmonary bypass or liver mobilisation depending on level
• Level I-IV classification used (Neves & Zincke)

For Metastatic RCC (Stage IV)

• Cytoreductive nephrectomy (followed by systemic therapy)
• First-line systemic agents:
  • Sunitinib / Pazopanib (VEGFR inhibitors) - intermediate/favourable risk
  • Ipilimumab + Nivolumab (dual checkpoint blockade) - poor/intermediate risk
  • Cabozantinib + Nivolumab - approved first line
  • mTOR inhibitors (temsirolimus, everolimus) for poor-risk disease
• Radiotherapy: Palliative (bone, brain mets)

PROGNOSIS

VIVA VOCE DISCUSSION POINTS

Gross haematuria + flank pain + palpable abdominal mass - present in <10% today, called the "too late triad" because it almost always indicates advanced disease. Most RCCs are now incidentally detected.

Band of colonic resonance anteriorly (bowel loops between kidney and anterior abdominal wall), ballotability, ability to get above the mass (unlike liver), and movement with respiration.

CECT abdomen - solid enhancing renal mass with >15 HU enhancement on contrast is virtually diagnostic. Biopsy is not routinely done pre-operatively if imaging is characteristic.

Yes. The adrenal gland is no longer routinely removed unless there is clear radiological or intraoperative evidence of direct tumour involvement.

Non-metastatic hepatic dysfunction in RCC - elevated liver enzymes and ALP without hepatic metastases. Caused by IL-6 secretion. Resolves after nephrectomy - its persistence post-op suggests residual/recurrent disease.

Expression of multidrug resistance (MDR) proteins - energy-dependent efflux pumps that expel cytotoxic agents. This has led to the use of targeted therapies (VEGF, mTOR, checkpoint inhibitors).

Mass per Abdomen - Clinical Case Presentation

As per S Das: A Manual on Clinical Surgery (13th Edition)

HOW TO PRESENT A CASE OF MASS PER ABDOMEN

SAMPLE CASE PRESENTATION

HISTORY

Chief Complaint

• Swelling in the abdomen for ___ months/years
• Associated with / without pain

History of Presenting Illness

• Duration - how long has the swelling been present
• Mode of onset - sudden or gradual
• Rate of growth - slow or rapid; whether the swelling has remained static, increased, or fluctuated in size
• Any relation to body position - does it disappear on lying down (hernia) or remain constant
• Pain - presence, character (colicky, dull ache, burning), radiation, aggravating and relieving factors
• Associated symptoms:
  • Haematuria (renal mass, bladder)
  • Haematemesis / Melaena (GI malignancy)
  • Jaundice (hepatic/biliary)
  • Altered bowel habits - constipation / diarrhoea (colonic pathology)
  • Urinary symptoms - frequency, hesitancy, retention
  • Loss of appetite and weight (malignancy)
  • Fever with chills (inflammatory/abscess)
  • Vomiting (gastric outlet obstruction)

Past History

• Similar swelling in the past
• Any previous surgery
• History of tuberculosis (mesenteric/abdominal)
• History of trauma

Personal History

• Diet, occupation (exposure to carcinogens)
• Menstrual history (in females - for pelvic masses)
• Bowel and bladder habits

Family History

• Similar complaints in family members

PHYSICAL EXAMINATION

General Examination

1. Built and Nourishment - emaciation, cachexia (malignancy)
2. Anaemia - pallor of mucous membranes (blood loss, chronic disease)
3. Jaundice - hepatic/biliary pathology
4. Lymph nodes:
   • Left supraclavicular (Virchow's/Troisier's sign) - S Das specifically stresses: "Before completing inspection, one should not forget to see the supraclavicular fossa particularly on the left side... These nodes are often secondarily involved (Troisier's sign) in breast carcinoma, abdominal carcinoma (especially of the stomach, pancreas or of the colon) and in malignant tumour of the testis."
   • Axillary nodes
   • Inguinal nodes
5. Oedema of lower limbs (IVC compression)
6. Clubbing (GI malignancy, cirrhosis)
7. Pulse, BP, Temperature, Respiratory rate

Do not forget: S Das specifically writes - "It should be made a routine to inspect the scrotum. Malignancy of the testis may lead to metastasis in the pre- and para-aortic lymph nodes. Swelling of these lymph nodes may be the first presenting symptom in these cases. If scrotum is not examined the entire diagnosis is missed."

LOCAL EXAMINATION OF THE ABDOMEN

INSPECTION

• Tense, red, shining = inflammatory swelling
• Pigmented = ? old scar, secondary deposits
• Engorged veins = portal/IVC obstruction

"Of these the position is the most important and should be described in relation to the nine anatomical regions of the abdomen."

1. Right hypochondrium | 2. Epigastrium | 3. Left hypochondrium
2. Right lumbar | 5. Umbilical | 6. Left lumbar
3. Right iliac | 8. Hypogastrium | 9. Left iliac

"Swellings arising from the liver, gallbladder, stomach and spleen move well with respiration. Swelling in connection with the kidney or suprarenal moves very little with respiration."

• Left-to-right = pyloric carcinoma (gastric outlet obstruction)
• Right-to-left = carcinoma of transverse colon
• Ladder pattern = small bowel obstruction

PALPATION

"Patient's confidence must be gained. The patient should lie flat on his back comfortably with one pillow below his head. Ask the patient to lie relaxed and breathe slightly deeply with mouth open. Under no circumstances he should be hurt."

• Flex hips and knees to relax abdominal muscles
• Clinician should sit on a chair or kneel so forearm is horizontal - volar surfaces of fingers used, NOT poking with fingertips
• Start from the area farthest from the swelling, proceed toward it last

"Swelling associated with the liver, gallbladder, spleen and stomach are movable with respiration. This is an up and down movement... Place the hand over the lower border of the swelling and ask the patient to take deep breath in and out. During inspiration the swelling will move downwards."

"The kidney moves very little with respiration."

1. Rising Test - Patient raises shoulders from bed with arms folded over chest
   • Parietal swelling = becomes more prominent and better defined
   • Intra-abdominal swelling = disappears or becomes less prominent
2. Leg Lifting Test (Carnett's Test) - Patient lifts both legs straight
   • Same interpretation as rising test

• Bimanual ballotement - one hand posteriorly in the loin pushes the kidney forward, the other hand on the anterior abdominal wall feels the kidney flip against it
• Positive in renal and retroperitoneal swellings

• If YES = not liver/spleen (unless massive)
• Renal swelling: can get above it

• Expansile = aortic aneurysm
• Transmitted = tumour lying in front of aorta
• Knee-elbow position test (S Das): In knee-elbow position, an anterior swelling hangs forward and loses pulsation; an aneurysm remains pulsatile

PERCUSSION

• Resonant = gas-filled viscus (gut)
• Dull = solid tumour, cyst, fluid-filled

"On percussion on anterior abdominal wall, the splenic swelling is dull all throughout but in case of a renal swelling a band of colonic resonance is obtained."

• Band of resonance anteriorly = renal swelling (colon lies anterior to kidney)

"Percussing the loin just outside the erector spinae. This area is normally resonant. With a renal tumour the resonance is replaced by dullness but with a splenic enlargement the normal resonance is preserved."

AUSCULTATION

• Bowel sounds - present/absent/exaggerated
• Bruit - over renal artery (RAS), hepatic artery (AVM)
• Succussion splash - for pyloric stenosis/obstruction: lay hand over epigastrium, make short jerky movements - audible gurgle indicates fluid in stomach

SPECIAL INVESTIGATIONS

DIFFERENTIAL DIAGNOSIS - SWELLINGS BY REGION

Right Hypochondrium

• Liver (hepatomegaly, abscess, hydatid, carcinoma, cirrhosis)
• Gallbladder (mucocele, empyema, carcinoma, hydrops)
• Hepatic flexure of colon (carcinoma)
• Right kidney / suprarenal
• Subphrenic abscess

Epigastric Region

• Stomach (carcinoma, pyloric stenosis)
• Liver (left lobe)
• Pancreas (pseudocyst, carcinoma)
• Abdominal aortic aneurysm (expansile pulsation - use knee-elbow position to confirm)
• Mesenteric lymph nodes (TB, lymphoma, secondaries)
• Retroperitoneal sarcoma/teratoma

Left Hypochondrium

• Spleen
• Stomach
• Left lobe of liver
• Splenic flexure of colon
• Tail of pancreas
• Left kidney / suprarenal

Umbilical Region

• Enlarged lymph nodes (TB mesenteric, lymphosarcoma, secondaries from testis)
• AAA (epigastric/umbilical)
• Transverse colon carcinoma

Right / Left Iliac Fossa

• Appendicular lump/abscess (right)
• Carcinoma caecum / ascending colon (right)
• Carcinoma sigmoid / descending colon (left)
• Ovarian cyst / tumour
• Pelvic abscess
• Undescended testis

S Das on carcinoma of the colon: "In the right half of the colon, the intestinal contents being of the fluid nature, obstruction is not an early feature... The patient complains of vague symptoms - loss of appetite, loss of weight, weakness, flatulence, dyspepsia. Anaemia is often present. The most important diagnostic finding is the presence of a lump at the site of the caecum or ascending colon."

"In the left half of the colon... the patient complains of increasing constipation requiring increasing dose of purgatives. No tumour is felt; what is felt is the loaded colon above the growth, as demonstrated by 'pitting on pressure' on the faecal matter."

HOW TO CONCLUDE YOUR PRESENTATION

"On the basis of history and clinical examination, I would like to summarize this as a [Age]/[Sex] patient with a [duration] history of a [location] abdominal swelling, which is [parietal/intra-abdominal], [mobile/immobile], [size], arising most likely from the [organ]. The most probable diagnosis is ____________. My differential diagnoses are ____________. I would like to confirm my diagnosis with [investigations]."

KEY CLINICAL PEARLS FROM S DAS

1. "Can you get above the swelling?" - If yes, it is not arising from the liver or spleen (unless massively enlarged). Renal swelling - you can get above it.
2. Band of colonic resonance is the single most important physical sign to distinguish a renal mass from a splenic mass.
3. Troisier's sign (left supraclavicular node) - must always be looked for in any abdominal swelling; if present, indicates intra-abdominal malignancy with lymphatic spread.
4. Ballotability - the definitive sign of a renal swelling.
5. Rising test / Carnett's test - differentiates parietal from intra-abdominal swelling.
6. Knee-elbow position - to differentiate expansile (aneurysm) from transmitted pulsation (pre-aortic mass).
7. Scrotal examination is mandatory - testicular malignancy can present as a para-aortic abdominal lump with no obvious primary.
8. The "too late triad" of renal cell carcinoma: haematuria + flank pain + palpable mass = almost always advanced disease.