Two Unusual Sites of Peritoneal Carcinomatosis

Sister Mary Joseph's Nodule. A dynamic occurrence of metastatic spread is the umbilical lesion known as Sister Mary Joseph's nodule. Named by Sir Hamilton Baily181,182 after the surgical assistant to Dr. William

Mayo, who first called his attention to this sign of intraabdominal malignancy,183 many hundreds of cases have now been reported.184,185 They are secondary, most commonly, to carcinomas of the stomach, ovary, colon, and pancreas. The umbilical nodules are usually 1-1.5 cm in diameter184 (Fig. 4-188), but lesions as large as 10 cm in diameter have been reported186 (Fig. 4-189). Frequently, the umbilical nodule is the initial presentation

187 188

of the internal primary malignancy. Most patients

187,188

die within months of its appearance. ' Various modes of spread to the umbilicus have been proposed, ranging from lymphatic or hematogenous dissemination via the

abdominal folds to seeded implants. The entity should be distinguished from seeded implantation during a surgical incision189 (Fig. 4-190) or implants of endometriosis.184

Krukenberg Tumors. A striking targeted pathway of seeding is occasionally encountered as the entity of Krukenberg tumors of the ovaries.190-194 These are usually secondary to gastric or colon mucinous adenocarcino-mas, are usually bilateral, and are associated with ascites (Fig. 4-191). Their likely pathogenesis has been recently elucidated as fixation and entrance of seeded cells at sites

Mucinous Carcinoma Peritoneal Implant

Fig. 4-183. Discrete nodular metastases on the greater omentum, demonstrated in two different cases.

(a) Contrast-enhanced CT shows multiple focal enhancing lesions on the fat-laden greater omentum anterior to the colon, metastatic from ovarian carcinoma.

(Courtesy of Robert E. Mindelzun, M.D., Stanford University School of Medicine, Palo Alto, CA.)

(b) High-resolution ultrasonography, magnified view, shows a thick, hypoechoic, homogeneous, and completely infiltrated omentum (O). A micronodular anterior surface (white dots) is further outlined by the ascites present. Also evident is an implant on the parietal peritoneum (P), shown by its acoustic interruption (between arrowheads). (Reproduced from Riioux and Michaud.131)

Fig. 4-183. Discrete nodular metastases on the greater omentum, demonstrated in two different cases.

(a) Contrast-enhanced CT shows multiple focal enhancing lesions on the fat-laden greater omentum anterior to the colon, metastatic from ovarian carcinoma.

(Courtesy of Robert E. Mindelzun, M.D., Stanford University School of Medicine, Palo Alto, CA.)

(b) High-resolution ultrasonography, magnified view, shows a thick, hypoechoic, homogeneous, and completely infiltrated omentum (O). A micronodular anterior surface (white dots) is further outlined by the ascites present. Also evident is an implant on the parietal peritoneum (P), shown by its acoustic interruption (between arrowheads). (Reproduced from Riioux and Michaud.131)

Omental Caking

Fig. 4-184. Omental caking from seeded pancreatic carcinoma.

CT in this patient following a Whipple operation demonstrates confluent soft tissue masses (arrows) separating the transverse colon from the anterior abdominal wall.

ileum or in a subsequent small bowel series. Computed tomography or MR imaging may readily demonstrate these. Seeding in other disparate sites may be related to adhesions from previous inflammation or abdominal operations.

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