IMAGING EVALUATION OF PRIMARY AND SECONDARY PERITONEAL MALIGNANCIES

review rticles IMAGING EVALUATION OF PRIMARY AND SECONDARY PERITONEAL MALIGNANCIES Evlución por imágenes de ls neoplsis peritoneles primris y secundris Ctlin Wilches, MD 1 Oscr M. Rivero, MD 2 Diego A. Aguirre, MD 2 Key words (MeSH) Peritoneum, peritonel neoplsm, CT-scn SUMMARY This rticle is review of the norml peritonel ntomy s seen on different cross sectionl imging modlities. The definitions nd demogrphic nd imging chrcteristics of primry nd secondry mlignncies involving the peritoneum re discussed for the pproprite ssessment of ptients with suspected peritonel pthology. 1 Resident IV th yer of Rdiology nd Dignostic Imging. Hospitl Universitrio Fundción Snt Fe de Bogotá. Bogotá, Colomi. 2 Institutionl Rdiologist. Body Imging Deprtment. Hospitl Universitrio Fundción Snt Fe de Bogotá. Bogotá, Colomi. Introduction The purpose of this rticle is to review the sic ntomy of the peritoneum using cross section dignostic imges nd its pthologicl implictions, in ddition to descriing the most frequent peritonel mlignncies. Just s in other ntomicl loctions, neoplstic peritonel processes re divided into: primry (these occur rrely) nd secondry. The peritoneum is usul route for the dissemintion of intr-dominl mlignncies including the most frequent GI trct pthology, s well s ovrin cncer, lung nd rest cncer nd melnom. The clinicl presenttion is unspecific. The ptient presents dominl pin nd loting, plple msses nd scites. Unfortuntely, most ptients re in dvnced stges of the disese t the time of dignosis, usully with diffuse peritonel neoplstic involvement. There re multiple dignostic imging modlities for evluting the condition. Multi-slice CT scn delivers the est ntomic resolution; MRI provides good soft tissue contrst nd etter ntomicl resolution; positron emission tomogrphy (PET) is not widely ville in our environment ut it enles stging nd restging, s well s the possiility to differentite etween tumor relpse vs. post-surgicl chnges. Ultrsound plys limited role in the ssessment of these pthologies ut llows for the identifiction of scites with retroperitonel implnts nd peritonel pseudomixom. Brekthroughs in CT scn llow for fine slices nd multiplnr reconstructions. The CT scnner using fine domen nd pelvic slices identifies su-centimeter implnts nd renders 3-D imges with less rtifcts nd dequte evlution of structures like the diphrgm, prietocolic gutters, the intestine nd the posterior cul-de-sc. Antomy of the Peritoneum The peritoneum is serous memrne covered y single lyer of mesothelil cells tht cots the complete domen. The peritonel spces re potentil spces not usully visulized unless they re distended y fluid or when there is thickening of the surrounding fsci. The domen cn e divided into suprcolic, infrcolic, pericolic nd pelvic spces. The supr Rev Colom Rdiol. 2010; 21:(3):1-11 1

nd infrcolic spces re divided y the trnsverse colon nd the mesenterium. In front the greter epiplon is locted etween the peritonel wll nd the intestine (1). The suprcolic spce includes the periheptic spces nd the trnscvity of the oment. The mesenteric root extends right to left from the ligment of Treitz to the ilieocecl re, seprting the infrcolic spce into the right nd left spces. On the outside, the pericolonic folds re communicted with the periheptic spces nd the pelvic region (1) Figs. 1 & 2). Usully there re less thn 50 ml of sterile fluid inside the cvity. This fluid is secreted y the viscerl surfce of the peritoneum nd, similr to lymph, with less thn 3,000 ce ls/mm 3 nd low protein content. Inside the peritonel cvity, the movement of fluid is cused y the negtive pressure re in the suphrenic spce, due to the movement of the diphrgm. By injecting fluid in the prcecl region, the fluid migrtes initilly into the suphrenic spce nd the pelvis; then it goes to the prietocolic gutter nd the suheptic spces. The fluid sorption in the peritoneum siclly tkes plce through the lymphtic circultion of the prietl peritoneum. There is lso fluid sorption t the diphrgmtic lymphtics, f c d e e Fig. 1. Antomy of the peritoneum. Right peritonel spce: ) periheptic; f) lesser sc. Left peritonel spce: ) nterior periheptic; c) posterior periheptic; d) nterior suphrenic; e) posterior suphrenic. f est f c f e Fig. 2. Antomy of the peritoneum. Right peritonel spce: ) periheptic; f) lesser sc. Left peritonel spce: ) nterior periheptic; c) posterior periheptic; d) nterior suphrenic; e) posterior suphrenic. Est = stomch. 2 Imging evlution of primry nd secondry peritonel mlignncies, Wilches C, Rivero OM, Aguirre DA

which re in turn responsile for trnsporting microorgnisms, cells nd other prticles present in the peritonel fluid (2). The peritoneum tht covers the muscle portion of the diphrgm hs intercellulr gps clled stomt, which re locted etween the mesothelil cells. Their size rnges etween 4 to 12 microns, depending on the diphrgm s stretching nd contrction. When inflmmtion occurs, the fluid nd the sustnces tht cnnot e sored y the peritonel memrne re trnsported y the stomt through fenestrtions of the sement memrne into specilized diphrgmtic lymphtic structures clled lcune. The relxtion of the diphrgm during expirtion opens the stomt nd promotes rpid filling of the lcune. During inspirtion, the contrction of the diphrgm empties the lcune into the efferent lymphtic chnnels nd pssing to the centrl circultion vi the thorcic duct (3, 4). It hs een found in niml models tht fter injecting cteri into the peritonel cvity, these cteri dispper immeditely to e found 6 minutes lter in the medistinum nd 12 minutes lter in the lood strem. It hs een determined s well tht the stomt my get clogged with prticles such s pltelets or tlcum powder. review rticles Then we will discuss the mjor peritonel primry nd secondry neoplsms, their imge presenttion nd the key dignostic fctors. Primry Peritonel Neoplsms Mlignnt Peritonel Mesotheliom Mlignnt mesothelioms re rre condition with high mortlity rtes (5-12 months in untreted ptients) (5-7). Usully it ffects 50 to 60 yer old mles, ut it my occur t ny ge (7,8). This condition is found to e ssocited to sestos exposure (6,8,9). There re two types of MPM: the diffuse type tht ehves s n infiltrting tumor, ssocited with irregulr nd nodulr thickening of the peritoneum nd scites (10,11); the focl type presents itself s heterogeneous mss with heterogeneous contrst enhncement. Contrry to pleurl mesotheliom, clcified plques re unusul in the peritonel mesotheliom (12). The CT findings re soft tissue msses, nodes, thickened peritoneum, scites or locl invsion of the intestine, the pncres, nd the liver (13, 14) (Fig.3). Fig. 3,. Mlignnt mesotheliom. Axil CT imges with evidence of diffuse nd nodulr thickening of the peritoneum, with ssocited scites. Liposrcom The liposrcom is very frequent tumor of the retroperitoneum nd reltively rre in the mesenterium nd the peritoneum (15, 16). There re severl histologicl types of which the myxoid is the most common. This condition does not differentite etween genders or typicl ge of presenttion (17). Both the CT scn nd the MRI show soft tissue mss with n dipose component in 40% of the cses. Finding n typicl lipom in the imges my ssist in mking differentil dignosis; i.e., n dipose mss with dditionl chrcteristics tht rule out the dignosis of lipom, including: irregulr sept or solid nodes inside (17) (Fig.4). Leiomiosrcom This is very vsculrized tumor. It shows up in the imges s heterogeneous mss with res or necrosis nd cystic formtions (Fig. 5) tht my cuse fistule nd perforte towrds the intestinl lumen or the peritonel cvity (18-20). The level of necrosis correltes to the histologicl grde of the tumor (21). There is no scites nd denomegly is rre (21-23). Leiomiosrcoms hve high rte of locl recurrence with metstses to the liver nd lungs (22,24). Rev Colom Rdiol. 2010; 21:(3):1-11 3

Fig. 4. Liposrcom. Axil CT showing peritonel mss with dipose component nd ssocited sept (typicl lipom presenttion). () Retroperitonel, solid, heterogeneous mss with no evidence of ftty component inside. Fig. 5.. Leiomiosrcom. Axil nd coronl plne CT scn imges depicting solid nd heterogeneous peritonel mss with lower density res inside. This is consistent with the confirmed histologicl dignosis of leiomiosrcom. Peritonel Srcom Peritonel srcoms re rre tumors with n incidence of 0.2% mong the generl popultion. They represent 50% of the primry mesenteric mlignncies nd their ppernce in imges depends on the histologicl type: liposrcom, leiomiosrcom, mlignnt firous histiocitom or firosrcom, which re fr less frequent thn in the retroperitoneum (25). The CT usully depicts them s lrge single msses (26) (Fig. 6,,), frequently infiltrting nd poorly defined. Peritonel Lymphom The involvement of the peritoneum in lymphom usully occurs in young ptients with clssicl plple dominl 4 mss. The CT shows group of lymph nodes round the ort nd the inferior ven cv tht does not compress the vsculr structures (27). Following the dministrtion of FDG, the PET imges depict hypermetolic nodes (Fig. 7..). Primry Benign Peritonel Neoplsms Lipom The peritonel lipom is enign tumor originting t the su peritonel ftty tissue. Usully is n incidentl finding (26). The imges show ftty ttenution mss without soft tissue involvement (26,28) (Fig. 8). Imging evlution of primry nd secondry peritonel mlignncies, Wilches C, Rivero OM, Aguirre DA

review rticles Fig. 6,. Peritonel srcom. Axil nd coronl TC imge showing solid peritonel irregulr nd heterogeneous mss, consistent with confirmed histologicl dignosis of srcom. Additionlly, the ft density cudl to the lesion is ltered. Fig. 7.. Peritonel lymphom. CT nd PET-CT xil views depicting focl peritonel hypermetolic lesions consistent with Hodgkin lymphom. Rev Colom Rdiol. 2010; 21:(3):1-11 5

Fig. 8,. Peritonel lipom. CT nd MRI xil view (T1 weighted imge) showing ftty mss tht thins out nd ulges the posterior right dominl wll (lumr region). These findings re consistent with the presence of lipom. Hemngiom The cvernous hemngiom is the most common hemngiom in the peritoneum, chrcterized y lrge pools of lood surrounded y endothelium nd lurred mrgins. It my look like hypo-dense heterogeneous mss (Fig 9,,). The presence of phleoliths in its imges is dignostic (26). Other less common vrints re the cpillry nd the venous hemngioms (29). Gnglioneurom These peritonel msses re more frequent in type 1 rther thn type 2 neurofiromtosis. The TC evidences multifocl, low ttenution mss (Fig, 10), rnching out or colescent, tht my mimic denomegly (26,30). This tumor hs heterogeneous enhncement with contrst medi (Fig. 10) nd my occsionlly show cystic ppernce. Fig. 9,. Hemngiom. Axil CT showing solid irregulr, heterogeneous nd hypodense mss, consistent with the histologicl dignosis of hemngiom. Diffuse Peritonel Leiomiomtosis This is usully n incidentl finding in reproductive ge women nd it is ssocited with high estrogen levels; i.e., during pregnncy or contrceptive use (26,31). The CT depicts multiple well-defined msses with myomlike enhncement. The MRI T1-weighted imges show s isointense muscle msses; contrst medi enhncement is vrile nd T2-weighted imges give low signl (26) (Fig.11-c). 6 Secondry Peritonel Neoplsms Peritonel Pseudomixom This is clinicl entity tht involves the peritonel surfces nd the omentum. It is chrcterized y the intrperitonel ccumultion of geltin-like mteril produced y the rupture of secondry cystic mucin-producing lesions or y primry mucinous cystdenocrcinom-like lesions; mostly the cecl Imging evlution of primry nd secondry peritonel mlignncies, Wilches C, Rivero OM, Aguirre DA

review rticles Fig. 10,. Gnglioneurom. CT xil views evidencing solid mss nd heterogeneous enhncement thn cn e due to gnglioneurom, with histologicl dignosis. c Fig. 11. Diffuse peritonel leiomiomtosis in pregnnt ptient (*) with intermedite signl diffuse peritonel mlignncy in different sequences. () Axil T1-weighted MRI imges; () T2-weighted coronl imges; (c) Axil post-contrst MRI evidencing diffuse enhncement of the peritonel neoplstic involvement. Rev Colom Rdiol. 2010; 21:(3):1-11 7

or ovrin ppendix nd less frequently the uterine, urchl or omphlomesenteric ppendix (32). Dignostic imges show multicystic thick-wlled mss or scites with sept inside nd curviliner or punctuted clcifictions (Fig. 12,) (32). Fig. 12. Peritonel Pseudomixom. () Axil view. (). Coronl CT with evidence of scites with sept inside nd contrst enhncement. Peritonel Crninomtosis The term peritonel crcinomtosis refers to the presence of soft-tissue implnts over the peritonel surfce (omentl cke). These implnts originte in primry tumor; usully rest, stomch, colorectl, pncretic or ovrin cncer. When ssocited with peritonel crcinomtosis, ovrin cncer is usully in n dvnced stge, cused y the circultion of peritonel fluid s previously descried. Tumor implnts vry in size nd cn e found from the diphrgm down to the pelvis (33), The domen nd the pelvis re evluted to stge the neoplsms, focusing minly on the sites tht re surgiclly difficult to ssess: the diphrgm, the splenic helium, the stomch, the lesser sc, the liver, the root of the mesenterium nd the prortic nodes ove the renl vessels (34, 35). Detecting these lesions is of clinicl vlue ecuse clinicl prmeters nd CT informtion re used for cncer stging nd to predict the surgicl outcome (36). Adequte tumor resection is chieved when there is evidence of residul disese >1 cm in dimeter. Imges re lso useful 8 to determine whether the ptient is cndidte for neodjuvnt chemotherpy prior to surgery. The dignostic imges show evidence of thickened lymph nodes of the peritoneum nd peritonel enhncement with contrst, ssocited with loculted scites (37-40) (Fig. 13). The most slient non-mlignnt entities to consider for differentil dignosis re: grnulomtous pthologies such s TB nd less often, peritonel histoplsmosis. Although the imging chrcteristics re like, there re some findings such s mesenteric mcronodules, omentl irregulrity, spleen clcifictions nd splenomegly tht enle the dignosis of TB (41.43). Peritonel Metstses The peritoneum is the trget of multiple metsttic processes, including the GI trct, GIST (gstrointestinl stroml tumor), the ovry (Fig 14,), the rest, the lung nd melnom (44). CT nd MRI re used for stging nd evlution of tumor relpses with peritonel involvement. The PET-CT is prticulrly useful in those cses in which CT nd MRI re negtive nd tumor mrkers re high (45). Imging evlution of primry nd secondry peritonel mlignncies, Wilches C, Rivero OM, Aguirre DA

review rticles Fig. 13,. Peritonel crcinomtosis. Axil CT imges. Different ptterns of crcinomtosis cn e identified due to the presence nodulr soft tissue lesions nd ssocited scites. Fig. 14,. Axil PET-CT imges in two ptients with dignosis of ovrin crcinom. The imges depict focl hypermetolic solid nodulr lesions. It is importnt to keep in mind tht since 18-fluorodeoxiglucose (18 FGD) is minly clered through the urine, the kidneys, the ureters nd the ldder hve n incresed uptke. Likewise, the intestine incresed uptke is norml ecuse of its own physiologicl ctivity ut this should not e mistken y hyper-uptke foci secondry to mlignncy. Furthermore, enign conditions involving the intestine, such s duodenl ulcers, colon polyps, intestinl inflmmtory disese or diverticulitis, mong others, present 18 FDG hyper-uptke (46, 47). GIST (Gstro-Intestinl Stroml Tumor) The primry tumor is chrcterized y its exophytic sumucosl mss ppernce in the GI trct, mostly present in the stomch nd the smll gut. It my exhiit hypovsculr or hypervsculr ehvior. 25% of the cses show clcifictions, necrosis (42,44,48). The PET imge depicts hypermetolic mss (Fig. 15,). This modlity is more sensitive thn the CT scn to ssess tretment response (45,49). Krukenerg Tumor The Krukenerg tumor is metsttic tumor of primry denocrcinom tht involves the ovry nd contins mucinsecreting cells in the signet-ring; usully it origintes in the rest or the GI trct, ut minly in the stomch (50,51). This tumor presents specific imging chrcteristics including complex ilterl msses with solid component (dense stroml rection) nd internl hyperintensity (mucin) in T1 nd T2 (52,53). Conclusion Peritonel neoplstic pthology occurs in different clinicl scenrios nd hving n dequte knowledge of the ntomy, the pthophysiology nd the ppernce on dignostic imges is crucil for correct interprettion. CT is the method of choice to ssess this pthology nd it is useful guide to iopsy those msses. MRI is n lternte dignostic modlity, more costly, does not generte ny ionizing rdition nd is good tool for Rev Colom Rdiol. 2010; 21:(3):1-11 9

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