Type:
Educational Exhibit
Keywords:
Cancer, Structured reporting, Staging, Diagnostic procedure, MR-Diffusion/Perfusion, MR, CT, Peritoneum, Oncology, Abdomen, Metastases
Authors:
M. A. Szadkowska1, J. Pałucki1, J. Podgorska2, A. Cieszanowski1; 1Warsaw/PL, 2Warszawa/PL
DOI:
10.26044/ecr2019/C-2611
Background
Peritoneal cavity
- a potential space confined by the parietal and the visceral peritoneum
- contains serosal fluid - 50-100ml
- the pathways of circulation of the peritoneal fluid explain the propensity of metastases for occupying certain compartments
The fluid accumulates in the most dependent recesses,
which are:
- the pouch of Douglas in women,
- the rectovesical recess in men,
- the right paracolic gutter,
- the right subhepatic recess (the Morison's pouch),
- the upper part of the sigmoid mesocolon and the caecum.
[1,
2]
Peritoneal metastases – most common places of origin
- most frequently originate from ovarian and gastrointestinal carcinomas
- other causes: carcinomas of the pancreas,
appendix,
biliary tract,
liver,
lung and genitourinary tract and sarcomas (gastrointestinal stromal tumors ) [2,3]
Differential diagnoses
Practically,
in the first place,
peritoneal carcinomatosis should be differentiated from lymphomatosis,
tuberculosis,
mesothelioma,
and pseudomyxoma peritonei.
[3]
1) Primary peritoneal malignancies [2,
3]:
- Malignant mesothelioma
- Cystic mesothelioma
- Primary peritoneal carcinoma
- Desmoplastic small round cell tumor
2) Pseudomyxoma peritonei
3) Peritoneal lymphomatosis [3]
4) Non-malignant conditions:
- Peritoneal tuberculosis
- Actinomycosis
- Splenosis implants
- Diffuse peritoneal leiomyomatosis
- Endometriosis [5]
- Ruptured ovarian teratoma (gliomatosis peritonei) [5]
- Meigs syndrome
Treatment options
- the best outcomes achieved in patients,
who underwent cytoreductive surgery and intraperitoneal chemotherapy (HIPEC or EPIC)
- results best documented in cases of colorectal cancer,
however patients suffering from ovarian cancer,
primary peritoneal carcinoma,
neuroendocrine tumors,
peritoneal mesothelioma and gastric cancer may also benefit
- the operative approach feasible only when optimal cytoreduction is possible and the patient can withstand the surgery,
- in some cases preoperative diagnosis has to be established by a biopsy; in most cases,
the qualification for surgery is based upon diagnostic imaging.
[6]
Cytoreductive surgery (CRS)
- aims at removing all the visible tumor
- may comprise such procedures as pelvic peritonectomy; removal of the sigmoid,
rectum,
mesorectum and female reproductive organs; greater omentectomy,
splenectomy and/or excision of the ascending colon; lesser omentectomy and resection of the gallbladder; single or multiple resections of different parts of the bowels; left hemidiaphragm peritonectomy and right hemidiaphragm peritonectomy with or without removal of the liver capsule and peritoneum covering the subhepatic recess.
[6]
Intraperitoneal Chemotherapy
1.
HIPEC (hyperthermic intraperitoneal chemotherapy) – directly after the end of a surgery,
chemotherapeutic agents heated up to 41-43℃ (to increase their cytotoxicity),
are administered into the abdominal cavity and left there for 1-1.5 hours.
Simultaneously,
a complementary chemotherapeutic agent is administered intravenously.
2.
EPIC (early postoperative intraperitoneal chemotherapy) – during the first days after the surgery,
several cycles of chemotherapy are administered to the peritoneal cavity through percutaneous catheters introduced to the abdominal cavity during a surgery.
[6]
Qualification for surgery
- a contrast-enhanced CT of the thorax,
abdomen,
and pelvis with the administration of oral contrast media (negative or positive),
to rule out extra-abdominal metastases,
pleural involvement,
and retroperitoneal lymphadenopathy,
- each lesion should be reported – its size,
location and proximity to other structures should be precisely described
Exploratory laparoscopy:
- an option for staging,
reserved for cases with equivocal findings
- less accurate than laparotomy,
which remains a gold standard [6]