Developments and Advances in Imaging

Multiple approaches have been applied in pursuit of refining the diagnostic accuracy of peritoneal carcino-

Fig. 4-185. Omental caking demonstrated secondary to ovarian carcinoma.

Tl-weighted gadolinium-enhanced fat-saturated MR image demonstrates enhancement of tumor implants on the greater omentum (arrows). (Reproduced from Ricke and Hosten.141)

Omental Cake Mri RadiopaediaGreater Omentum

Fig. 4-187. Omental varices.

The greater omentum, in contrast to the small bowel mesentery, has scanty vascular structures. In this patient with portal hypertension and ascites, omental varices (arrows) may mimic omental infiltration from carci-nomatosis or peritonitis.

Fig. 4-186. Omental inflammation.

CT demonstrates inflammatory infiltration of the greater omentum (arrowhead), consequent to a perforated gastric ulcer (arrow) arising from the greater curvature of the stomach. (Courtesy ofJames Drink, M.D., Yale University School of Medicine, New Haven, CT.)

Fig. 4-187. Omental varices.

The greater omentum, in contrast to the small bowel mesentery, has scanty vascular structures. In this patient with portal hypertension and ascites, omental varices (arrows) may mimic omental infiltration from carci-nomatosis or peritonitis.

Omental VaricesSister Mary Nodule

Fig. 4-188. Sister Mary Joseph's nodule.

A soft tissue mass (arrows) is present in the subcutaneous tissue at the level of the umbilicus, metastatic from a primary gastric adenocarcinoma. Note that it causes no discernible bulge of the skin surface. Generalized ascites is seen.

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

Sister Josephs Nodule

Fig. 4-189. Sister Mary Joseph's nodule.

CT demonstrates a large umbilical nodule with central necrosis (arrows). In this 33-year-old male with adenocarcinoma of the esophagogastric junction, carcinomatosis included a lesser omental mass (coronary lymphadenopa-thy) and bilateral adrenal metastases.

Fig. 4-189. Sister Mary Joseph's nodule.

CT demonstrates a large umbilical nodule with central necrosis (arrows). In this 33-year-old male with adenocarcinoma of the esophagogastric junction, carcinomatosis included a lesser omental mass (coronary lymphadenopa-thy) and bilateral adrenal metastases.

Fig. 4-190. Incisional recurrence mimicking a Sister Mary Joseph's nodule.

Tumor cells seeded at a surgical incision yield a subcutaneous mass (closed arrow) that appears to extend into the fat pad of the falciform ligament. This is associated with enhancement and thickening of the peritoneum (open arrows) and ascites in this patient with peritoneal carcinomatosis. It remains questionable whether the mass truly represents an umbilical metastasis that developed after the surgical procedure.

Photo Vascular Carcinomatosis

matosis. Whereas CT may clearly demonstrate localized or diffuse involvement of the peritoneum and its reflections and recesses, it is not reliable for low-volume tumor on peritoneal surfaces, and its greatest inaccuracies have been recorded in the pelvis.208 Contrast enhancement of ascites in peritoneal carcinomatosis on delayed images in CT209-211 may obscure peritoneal implants of soft tissue density. This enhancement probably results

010 919-914

from increased vascular-peritoneal permeability. ' Similar results have been reported for MRI using delayed gadolinium-enhanced sequences.138,215 Positive-contrast peritoneography has been used in the demonstration of abdominal metastases.70,216,217 When coupled with CT,218-222 it may further enhance the demonstration of small peritoneal lesions (Fig. 4-196), but small implants in curved recesses may be missed on axial sectional imaging. CT with induced pneumoperitoneum widi C02 has been reported with disclosure of implants even <2 mm in size (Fig. 4-197), but with significant limitations.223 Abdominal ultrasonography has revealed signs for peritoneal carcinomatosis that account for malignant ascites in 78-92% of cases.224-227 Using highresolution ultrasonography, Rioux and Michaud132 documented omental, serosal, and peritoneal implants.

102,228

Following early reports, ' MRI detection of peritoneal implants has been accelerated with technological

Peritoneal Carcinos

Fig. 4-191. Bilateral Krukenberg tumors of the ovaries secondary to gastric carcinoma.

The ovarian masses are clearly evident (arrows), highlighted by massive ascites. (Reproduced from Gore and Meyers.24)

Fig. 4-191. Bilateral Krukenberg tumors of the ovaries secondary to gastric carcinoma.

The ovarian masses are clearly evident (arrows), highlighted by massive ascites. (Reproduced from Gore and Meyers.24)

Peritoneal Mesothelioma Radiology

Fig. 4—192. Peritoneal mesothelioma.

(a and b) Contrast-enhanced CT reveals diffuse infiltration of the greater omentum and small bowel mesentery with tumor. Ascites is a less impressive finding with peritoneal mesotheli-oma than it is with peritoneal carcinomatosis.

(Courtesy of James Brink, M.D., Yale University School of Medicine, New Haven, CT.)

Peritoneal Carcinomatosis

Fig. 4-193. Peritoneal lymphomatosis.

Extensive tumor spreads along the peritoneal and mesenteric surfaces. Despite prominent compression of the mesenteries, the intrinsic intramesenteric fat is preserved. (Courtesy of Robert Mindelzun, M.D., Stanford University School of Medicine, Palo Alto, CA.)

Fig. 4-193. Peritoneal lymphomatosis.

Extensive tumor spreads along the peritoneal and mesenteric surfaces. Despite prominent compression of the mesenteries, the intrinsic intramesenteric fat is preserved. (Courtesy of Robert Mindelzun, M.D., Stanford University School of Medicine, Palo Alto, CA.)

Serous Peritoneal Implants

Fig. 4—194. Subcutaneous implant tumor from serous ovarian carcinoma following paracentesis.

Four months after paracentesis with an intraperitoneal catheter that was left in situ for 24 hours, CT shows a large solid inhomogeneous mass in the subcutaneous tissue in the paracentesis site. Part of its margins infiltrate fatty tissue. This was proved to be an infiltrative metastatic implant. (Reproduced from La Fianza, et al.206)

Fig. 4—194. Subcutaneous implant tumor from serous ovarian carcinoma following paracentesis.

Four months after paracentesis with an intraperitoneal catheter that was left in situ for 24 hours, CT shows a large solid inhomogeneous mass in the subcutaneous tissue in the paracentesis site. Part of its margins infiltrate fatty tissue. This was proved to be an infiltrative metastatic implant. (Reproduced from La Fianza, et al.206)

Peritoneal Metastatic Implants

Fig. 4-195. Peritoneal seeding at site of needle track.

Eight months after percutaneous ethanol ablation therapy for hepatocellular carcinoma.

(a) CT shows small firm nodules at the sites of the punctures attached to the peritoneum (white arrows). Part of the primary tumor is indicated (black arrow).

(b) Ultrasound demonstrates the three small inhomogeneous nodules (arrows) attached to the peritoneum

(curved arrow).

(Reproduced from Kurl et al.207)

Fig. 4-195. Peritoneal seeding at site of needle track.

Eight months after percutaneous ethanol ablation therapy for hepatocellular carcinoma.

(a) CT shows small firm nodules at the sites of the punctures attached to the peritoneum (white arrows). Part of the primary tumor is indicated (black arrow).

(b) Ultrasound demonstrates the three small inhomogeneous nodules (arrows) attached to the peritoneum

(curved arrow).

(Reproduced from Kurl et al.207)

improvements. Seeded peritoneal metastases may be evident as discrete nodules59,106,132,140 or as peritoneal thickening and enhancement.138 Saline MR peritoneography, heavily T2-weighted images in conjunction with intraperitoneally instilled saline, may enhance the detection of small implants on peritoneal surfaces.229 Ra-dioimmunoscintigraphy230 may be applied to the detection of peritoneal carcinomatosis.

Lymphomatosis

Fig. 4—196. Peritoneal seeded metastases.

CT after intraperitoneal infusion of contrast medium demonstrates filling defects in right upper quadrant (arrows) representing studding of peritoneal surface from metastases. (Reproduced from Dunnick et al.218)

Fig. 4—196. Peritoneal seeded metastases.

CT after intraperitoneal infusion of contrast medium demonstrates filling defects in right upper quadrant (arrows) representing studding of peritoneal surface from metastases. (Reproduced from Dunnick et al.218)

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