Subdiaphragmatic Peritoneal Implants

Subdiaphragmatic SpaceRight Subphrenic Space Paracolic Gutter Peritoneal Seeding

Fig. 4-150. Simultaneous metastatic seeding in Morison's pouch and the right subphrenic space.

Three different examples illustrate the range of magnitude from minimal deposits to masses (M) of varying sizes and shapes. The primary tumors were:

(a) Endometrial carcinoma.

(b) Carcinoma of the ovary. (Reproduced from De Meo, et al.111)

(c) Pineal germinoma, with peritoneal dissemination via a ventriculo-peritoneal shunt. (Courtesy of Hiromu Mori, M.D., Oita Medical Center, Oita, Japan.)

Fig. 4-150. Simultaneous metastatic seeding in Morison's pouch and the right subphrenic space.

Three different examples illustrate the range of magnitude from minimal deposits to masses (M) of varying sizes and shapes. The primary tumors were:

(a) Endometrial carcinoma.

(b) Carcinoma of the ovary. (Reproduced from De Meo, et al.111)

(c) Pineal germinoma, with peritoneal dissemination via a ventriculo-peritoneal shunt. (Courtesy of Hiromu Mori, M.D., Oita Medical Center, Oita, Japan.)

Fig. 4—151. Peritoneal—pleural communication.

Anterior scinti-image of upper abdomen and chest 2 hours after instillation of Tc99m sulphur colloid into the peritoneal cavity demonstrates visualization of anterior mediastinal lymphatic channels and passage of radiotracer into the right hemothorax. (Reproduced from Mittal, et al.119)

have peritoneal implants at autopsy, and 60-70% have

ascites.

It is being increasingly recognized that metastatic ovarian implants along the right hemidiaphragm and liver capsule are frequent. Peritoneoscopic studies have shown metastatic diaphragmatic involvement in 61% of patients with ovarian carcinoma,121 and, more significantly, that in 21-34% of patients otherwise diagnosed as having stage I or stage II disease, there is seeding on the undersurface of the diaphragm, particularly on the right. 122-125 These implants are generally only 2-3 mm in diameter (Fig. 4-153), but may reach a size of several centimeters126 (Figs. 4-154 and 4-155).

The perihepatic dissemination of ovarian carcinoma is now being increasingly detected by CT. Peritoneal implants may be seen as nodular, plaquelike, or sheetlike masses127,128 (Figs. 4-150, 4-156 through 4-159), and deposits as small as 5 mm from ovarian carcinoma may be detected, often outlined by ascites. 126,128-130 Highresolution ultrasonography may demonstrate even minute metastases when they are seeded on the anterior peritoneum131 (Fig. 4-160). Notable sites of implantation are the falciform ligament and interhepatic fissures (Figs. 4-161 and 4-162). Accurate identification of peritoneal implants is particularly important since cy-

Omentum Nodule And Falciform

Fig. 4—152. Pericardiac lymphadenopathy secondary to metastatic pancreatic carcinoma.

CT demonstrates an enlarged anterior mediastinal lymph node (arrow).

Fig. 4—152. Pericardiac lymphadenopathy secondary to metastatic pancreatic carcinoma.

CT demonstrates an enlarged anterior mediastinal lymph node (arrow).

Peritoneal Impants

Fig. 4—153. Perihepatic seeded ovarian carcinoma shown by peritoneoscopy.

Multiple small nodules are present on the liver (L) and the parietal peritoneum (PP) of the abdominal wall and diaphragm (D). A = ascites; GO = greater omentum. (Courtesy of Charles Lightdale, M.D., New York.)

toreductive surgery is of value in improving survival if all intraabdominal masses greater than 1.5 cm in diameter can be removed.133-135 Implants in the porta hepatis and interlobar fissure indicate tumor nonresectability.B6

Fig. 4-154. Right subdiaphragmatic implants from ovarian carcinoma.

MRI, Tl-weighted axial image, demonstrates seeded metastases from ovarian carcinoma on the diaphragmatic parietal peritoneum on the right (arrow). (Reproduced from Chou et al.102)

Fig. 4-154. Right subdiaphragmatic implants from ovarian carcinoma.

MRI, Tl-weighted axial image, demonstrates seeded metastases from ovarian carcinoma on the diaphragmatic parietal peritoneum on the right (arrow). (Reproduced from Chou et al.102)

Minimal Subdiaphragmatic Collection MriOtosclerosis Findings

Fig. 4-155. Seeded implants along the diaphragmatic surface and the liver capsule from fallopian tube carcinoma.

Coronal T2-weighted MR image demonstrates an irregular layer of metastatic deposit measuring up to 2 cm in thickness along the parietal peritoneum of the diaphragm and the liver capsule (arrows).

(Reproduced from Semelka et al.59)

Fig. 4-155. Seeded implants along the diaphragmatic surface and the liver capsule from fallopian tube carcinoma.

Coronal T2-weighted MR image demonstrates an irregular layer of metastatic deposit measuring up to 2 cm in thickness along the parietal peritoneum of the diaphragm and the liver capsule (arrows).

(Reproduced from Semelka et al.59)

Parietal peritoneal thickening with contrast enhancement of the peritoneum, making the peritoneum visible as a smooth or nodular line along the abdominal wall, representing confluent seeded deposits, may be conspicuous (Fig. 4-163). In one series of patients with peritoneal tumor spread studied by CT, it was evident in 62%.137 Refinements in MR imaging, in which the examination protocol focuses on T1-weighted fat-saturated sequences after application of gadolinium, similarly lead to detection ofperitoneal carcinomatosis59,138-141 (Fig. 4-164). It has also been re ported in tuberculous peritonitis137, 142-147 (Figs. 4-165 and 4-166), other infectious processes of the peritoneum148,149 (Fig. 4-167), mesothelioma,150 and peritoneal endometriosis.151

In mucinous cystadenocarcinoma of the ovary, the gelatinous material produced by seeded metastases may be first seen as a mantle over the right lobe of the liver (Figs. 4-168 and 4-169).

With progression to the condition known as pseu-

domyxoma peritonei, the characteristic findings of scalloping of the liver edge by the cystic collections and

Scallop Edge Mesothelioma

Fig. 4—156. Perihepatic seeded implants from ovarian carcinoma.

Multiple deposits on the liver capsule result in a scalloped contour.

Fig. 4—156. Perihepatic seeded implants from ovarian carcinoma.

Multiple deposits on the liver capsule result in a scalloped contour.

septated ascites may be evident153-155 (Figs. 4-170 through 4-173). In this entity, the primary tumor usually occurs within the appendix or ovary. Related to the surface adherence of the high-grade cells, there is a notable lack of tumor on bowel surfaces that are active in peristalsis. Thus, the greatest volumes of cancer are beneath the diaphragms and in the pelvis. The greater and lesser omentum also contain a relatively larger volume of tumor.156

Delineation by the falciform ligament is a characteristic landmark of the process of intraperitoneal seed-ing.70,94

Dense, punctate perihepatic calcifications in a case of pseudomyxoma peritonei from mucinous adenocarci-noma of the appendix following intraperitoneal che-

motherapy has been reported. Diffuse intraperitoneal gelatinous metastases from mucin-producing teratocar-cinoma of the testis in which the peritoneal cavity was seeded during retroperitoneal lymphadenectomy has

been observed.

In serous cystadenocarcinoma of the ovary, calcified perihepatic metastatic implants may be de-tected.128,137,159-161 This is the most common type of ovarian carcinoma and contains histologic calcification, psammoma bodies, in approximately 30% of cases.162 The perihepatic calcifications are seen related to the right hemidiaphragm (Fig. 4-174) and liver surface (Figs. 4-175 and 4-176), even up to the immediate subphrenic region (Fig. 4-177), as well as on the falciform ligament (Figs. 4-162b and 4-176). Calcified implants have also been noted in the right paracolic gutter, in text continues on page 229

Fig. 4-157. Metastatic "caking" of the parietal peritoneum.

Seeded metastases from ovarian carcinoma have resulted in plaquelike thickening of the parietal peritoneum lateral to the right lobe of the liver (arrows). Mesenteric masses (M) are also present.

(Courtesy of Michiel Feldberg, M.D., Ph.D., University of Utrecht, The Netherlands.)

Fig. 4—158. Plaquelike seeding on diaphragmatic peritoneum.

Intraperitoneal seeding from an anaplastic carcinoma, site unknown, results in marked thickening of the diaphragmatic parietal peritoneum, particularly on the right (arrows). Ascites is present.

(Courtesy of Emil Balthazar, M.D., Bellevue Hospital—New York University School of Medicine, New York.)

Fig. 4—158. Plaquelike seeding on diaphragmatic peritoneum.

Intraperitoneal seeding from an anaplastic carcinoma, site unknown, results in marked thickening of the diaphragmatic parietal peritoneum, particularly on the right (arrows). Ascites is present.

(Courtesy of Emil Balthazar, M.D., Bellevue Hospital—New York University School of Medicine, New York.)

Fig. 4-159. Perihepatic diaphragmatic metastatic nodules.

Seeded implants from ovarian carcinoma are seen as prominent nodular masses on the parietal peritoneum overlying the diaphragm impressing upon the liver. Ascites is present.

Subdiaphragmatic Implant

Fig. 4-160. Small anterior peritoneal implant.

Ultrasonography shows a 3-mm implant (between arrowheads), revealed as a focal hypoechoic linear interruption of the normally hyperechoic parietal peritoneum (p). L = liver.

(Reproduced from Rioux and Midlaud.131)

Fig. 4-161. Falciform ligament implant.

A large metastasis from a myxoid liposarcoma of the pelvis has deposited on the falciform ligament (iarrow).

Subdiaphragmatic PeritoneumSubdiaphragmatic Peritoneum
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Responses

  • kristen
    What is multiple implants in the subdiaphragmatic mean?
    4 months ago

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