Download Peritoneal carcinomatosis

Peritoneal carcinomatosis. How
to detect early signs
M. Ave-Seijas
V.Taboada
L. Trillo
R. Bouzas
CHUVI-HospitalXeral-CíesVigo/ES
Learning Objective

To illustrate peritoneal carcinomatosis early
manifestations with MDCT

Special emphasis is placed on depicting the
different peritoneal recesses using multiple
projections through multiplanar reconstruction
Background

Peritoneal carcinomatosis is a challenge for MDCT,
and variability in the sensitive to detect early sings is
probably common between different radiologists

We retrospectively reviewed MDCT findings of 33
patients with histopathological diagnosis of peritoneal
carcinomatosis between 2005 and 2008, focusing this
review in non ovarian tumors

MDCT were interpreted by six radiologists. Only two of
them were specialists in abdominal imaging
Imaging Findings
I- Peritoneal anatomy

The peritoneal cavity is the virtual space between the
visceral and parietal layers of the peritoneum

The distribution of disease within the peritoneal cavity
is determined by many factors, including gravity,
changes in abdominal pressure with respiration and
the peritoneal reflection, which may limit the spread of
the disease [1,2,3]
II.- Peritoneal carcinomatosis
Diffuse metastatic spread within the peritoneal
cavity
 Mestastases are usually from intra-abdominal
primary neoplasms, such as ovarian carcinoma in
women and stomach, colon, pancreas in both
genders
 According to several studies the most common
sites of peritoneal seeding include the pelvis, right
lower quadrant, right paracolic gutter and the
superior aspect of the sigmoid mesocolon [3,4]


Metastases spread throughout the peritoneum in
four ways:
 Direct tumor invasion or along peritoneal ligaments,
mesenteries and omenta to non-contiguous structures
 Intraperitoneal seeding via ascitic fluid flow
 Lymphatic extension
 Haematogenous spread
III.- Imaging techniques for the detection of peritoneal
carcinomatosis
There is not a completely optimal imaging
technique for detecting peritoneal carcinomatosis
Computed tomography(CT) is the most used tool. CT
has a sensitivity less than 50% in detecting
peritoneal metastases, but the specifity exceeds
85% and the sensitivity is improved in peritoneal
deposits greater than 1 cm [5]
Other imaging techniques:
 Abdominopelvic ultrasound can detect ascites and
depict peritoneal implants, but it is an operatordependent technique and time consuming

Magnetic Resonance Imaging(MRI) has a superior tissue
contrast compared with CT, but its spatial resolution is
lower. Recent studies say that comparing with singlephase helical CT, it shows an advantage in depicting
tumor involving the peritoneum, omentum and bowel [6,7]

Positron Emission Tomography-CT(PET-CT) has
limitations in detecting mucinous tumors and can have
false-positive results in cases of acute inflammation or
active tissue repair
NOWADAYS, CT IS THE IMAGING STANDARD TO
EVALUATE PERITONEAL CARCINOMATOSIS, AND
MRI AND PET-CT ARE CONSIDERED USEFUL BUT
NOT FUNDAMENTAL [8,9]
IV- CT findings of peritoneal carcinomatosis






Ascites, usually loculated
Thickening of the parietal peritoneum, either smooth or
nodular
Scalloping of the liver or splenic surfaces
Alteration of the greater omentum
Affectation of the mesentery
Bowell involvement
WE ALSO ASSESS EXTRAPERITONEAL ABDOMINAL DISEASE
SECONDARY TO HEMATOGONOUS SPREAD, INCLUDING LIVER
METASTASES
Ascites usually loculated
Fig. 2. Axial CT scan shows hepatic
loculated fluid.
Fig. 1. Coronal CT scan shows
lateroconal left fascia thickening
and large amounts of ascites with
atypical distribution.
Fig. 3. Axial CT scan shows fluid in the culde-sac. Typical place of ascites.
Thickening of the parietal peritoneum
Fig. 4. a) Axial and b) coronal CT scans
shows bilateral thickening of
lateroconal fascia and loculation of
subhepatic fluid in both paracolic
gutters.
A
a
b
Thickening of the parietal peritoneum
Fig. 5: Bilateral thickening
of lateroconal fascia
“Scalloping” of the liver or splenic surfaces
Implants located between the diaphagmatic peritoneum and the liver or
the spleen
Fig.6. Axial CT scan shows scalloping of the hepatic
margin and a large amount of ascites.
Alteration of the greater omentum
Soft-tissue permeation of omental fat, nodules or thickened
omentum with diffuse tumor infiltration (omental cake)
Fig.7. Axial CT scan
shows soft-tissue
permeated omental fat.
Fig.8. Axial CT scan
shows omental nodules.
Fig.9. Axial CT scan shows
diffuse omental infiltration
(omental cake).
Alteration of the greater omentum
a
b
Fig. 10. a) Axial CT scan shows soft-tissue permeation of omental fat. b) Axial CT
scan after surgery shows bowell dillatation( )with nodular thickened wall(
)due
to extensive carcinomatosis. Initial changes (a) were interpreted as postsurgery
changes.
Affectation of the mesentery
Soft-tissue permeation of mesenteric fat, nodules or masses and
lymph nodes increased in number or size
Fig.11. Axial CT scan shows soft-tissue
permeation of mesenteric fat
Combination of signs
Fig. 12. Coronal CT scan shows
mesenteric masses and loculated
ascites
Fig.13. Axial CT scan shows bilateral
lateroconal fascia (
) thickening,
loculated fluid (
)and mesenteric
masses (
).
Fig. 12. Axial CT scan shows complex
cystic mass in lesser sac (
) and
peritoneal tumour implant (
).
Fig. 13. Coronal MIP CT scan shows
small mesenteric lymph nodes.
Bowell involvement
Thickening and nodularity of the bowel wall
Fig.14. Axial CT scan shows thickening
of the bowel wall and loculated fluid.
V.- Data:



These 33 patients were divided into two groups. In one group (A)
peritoneal carcinomatosis was diagnosed on the first MDCT, and in the
other group (B) we included those who had at least one MDCT
performed 3 to 6 months before the establishment of the diagnosis of
carcinomatosis. In this last group we actively searched for conclusive
signs of carcinomatosis and possible causes of delayed diagnosis,
especially due to misperceptions, and therefore false negatives. We
illustrate the differences between those groups. We use 10 abdominal
MDCT obtained in patients with no cancer history as control group for
comparison
We settle a search pattern in the abdomen dividing it into quadrants
(right upper quadrant:RUQ, left upper quadrant:LUQ, right lower
quadrant:RLQ and left lower quadrant:LLQ)
We analyzed a change in the fascia morphology, the liver surface,
mesentery, omentum, bowel wall and the presence of ascites, lymph
nodes, and liver metastasis, and illustrate evolution between both
MDCT
PRIMARY TUMOR
Group A: unknown (5), gastric (5), colon (2), pancreas (2), neuroendocrine (1), lung (1)
endometrium (1)
Grupo B: gastric (4), colon (4), unknoum(3), carcinoid (2) pancreas (1) hypernephroma
(1), gallbladder(1)
Percentages of CT findings in two groups
Group A
Group B
Ascites
88,2 %
43,8%
Parietal
Peritoneum
47%
75%
“scallopig”
11,8%
6,2%
Greater
Omentum
35,3%
25%
Merentery
47%
12,5%
Mesentery
lymph nodes
47%
62,5%
liver MTS
23,53%
12,5%
Only one of the patients
in the control group
showed peritoneal
involvement, as free fluid
secondary to
adherences, which was
detected in all quadrants
CT findings in group A (peritoneal carcinomatosis diagnosed on the first MDCT)
N:17 patients
RUQ
LUQ
RLQ
LLQ
Ascites: 15
12
9
11
14
1
9
7
4
3
Parietal
Peritoneum:
8
Perihepatic
Paracolic
gutter
“scallopig”:2
8 patients had
mesenteric lymph
nodes, and 4 had
liver metastasis
1
Greater
Omentum:6
Soft-tissue
Nodules
Omental Cake
0
5
1
0
5
1
0
3
1
0
3
1
Merentery:8
Soft-tissue
Nodules
5
2
3
1
2
0
2
0
CT findings in group B (MDCT performed 3 to 6 months before the establishment of
the diagnosis of carcinomatosis)
10 patients had
mesenteric
lymph nodes,
and 2 had liver
metastasis
N:16 patients
RUQ
LUQ
RLQ
LLQ
Ascites:7
3
3
5
3
8
9
1
7
1
-
1
-
-
-
Parietal
Peritoneum
12
Perihepatic
Paracolic
gutter
“scallopig”1
Greater
Omentum:4
Soft-tissue
Nodules
Omental Cake
2
0
0
2
-
1
-
1
-
Merentery:2
So
nodules
2
0
1
-
1
-
-
CASE 1
a
b
Fig. 1. A 67 year-old man with colon carcinoma. a) Axial CT scan shows a small
parietal peritoneal implant in the right hepatic lobe (
). b) Coronal CT
scan shows the parietal peritoneal implant. We observe an ondulation of the
hepatic surface (
) caused by muscular slip of the diaphragm that can
mimic the appearance of peritoneal thickening.
Fig. 2. Axial and coronal consecutives CT scans show a small parietal peritoneal implant
in the right hepatic lobe, larger in last CT.
The diagnosis of peritoneal carcinomatosis was established on the last CT
a
b
Fig. 3. a) Coronal and b) coronal MIP CT scans show mesenteric small
lymph nodes. Small lymph nodes are associated with early signs of
peritoneal carcinomatosis.
CASE 2
a
Fig. 1. A 65 year-old man with T4 N1 M1 gastric cancer that was understaged as T4 N1
M0. a) Coronal CT scan shows gastric wall thickening and small local lymph nodes. b)
Axial CT scan shows discrete permeation of omental fat with separation of a small bowell
loop from the abdominal wall (early sign of omental disease)
b
b
a
Fig. 2. Images obtained in 65 year-old man with T4 N1 M1 gastric cancer after surgery. a)
Coronal CT scan shows gastric wall thickening and mesenteric small lymph nodes. b)
Axial CT scan shows nodular thickened omentum.
CASE 3
b
a
Fig. 1. A 69 year-old man with colon
carcinoma. a) Coronal CT scan shows
thickening of the parietal peritoneum (
) in
the right hepatic lobe and nodular thickening
of the paracolic gutter (
). Also b) axial
CT scan shows nodular thickening of the
perihepatic parietal peritoneum.
c) Coronal CT shows a mesenteric mass(
c
A radiologist with experience in abdominal
imaging interpreted the images
)
Fig. 2. Images obtained 6 months
before . a) Coronal CT scan shows
subtle thickening of the parietal
peritoneum (
) in the right hepatic
lobe and nodular thickening of the
paracolic gutter (
). b) Axial CT
scan shows subtle nodular thickening
of the perihepatic parietal
peritoneum.
c) Coronal CT demonstrates small
mesenteric masses(
).
These subtle findings were not
described by the radiologist
CASE 4
a
Fig. 1. A 60 year-old man with metastatic adenocarcinoma. a) Axial CT scan
shows a minimum detectable amount of free perihepatic fluid and hepatic
metastases. In b) Axial CT scan, free intraperitoneal fluid is not detected in
other peritoneal spaces
b
a
b
Fig. 2. Images obtained 3 months later. a) Axial CT scan shows increase of amount
of free perihepatic fluid. b) Coronal CT scan shows free intraperitoneal fluid in perihepatic
space, periesplenic space, both paracolic gutters and pelvis.
b
a
Fig. 3. Images obtained 6 months later in the same patient. a)
Coronal, b) axial, and c) axial CT scan show large amounts of
ascites in all compartments: perihepatic space, periesplenic space,
mesentery, both paracolic gutters and pelvis.
c
VI.-Discussion

In group A (peritoneal carcinomatosis diagnosed on the first
MDCT), the most common CT finding of peritoneal
carcinomatosis was ascites, present in 88,2 % of patients,
without predilection for any abdominal quadrant

In group B (who had at least one MDCT performed 3 to 6
months before the establishment of the diagnosis of
carcinomatosis ), the most common CT finding (75% of
patients) was thickening of the parietal peritoneum,
predominating in the right upper quadrant
Soft-tissue permeation of omental fat is most frequent in
group A, and nodules or omental cake in group B
 Multiple and small lymphadenopathy, in conjunction with
other signs, should warn of the presence of peritoneal
dissemination


We must pay special attention to the search for subtle
signs of peritoneal carcinomatosis in stomach and colon
carcinomas (non ovarian tumors)

Moreover, in patients with minor volume ascites, it allows
a better evaluation of the parietal or visceral peritoneum

The use of multiple projections through multiplanar
reconstruction aids to the detection of a subtle thickening
of the peritoneal recesses

Interpretation of MDCT by abdominal imaging
radiologists may reduce the false negative of peritoneal
carcinomatosis
Conclusions

The diagnosis of peritoneal carcinomatosis is a real challenge for the
radiologist. Natural history can teach us how to integrate signs into a
standard report

Our study is retrospective and its validity must be confirmed by
prospective studies. But this study shows the most common
anatomical sites where you could find subtle signs of peritoneal
carcinomatosis

To increase the sensitivity for the detection of peritoneal
carcinomatosis, allowing better surgical or medical oncology treatment,
the radiologist should focus in the upper right quadrant and the greater
omentum
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