Peritoneal metastases
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Peritoneal metastases (also known as peritoneal carcinomatosis when extensive) are relatively common particularly in tumours of the abdomen and pelvis and generally imply a poor prognosis, often with a significant impact on palliation.
Epidemiology
The epidemiology of patients with peritoneal metastases mirrors that of affected patients. Common primaries include 1-2:
- ovarian cancer
- gastric cancer
- colorectal cancer
- appendiceal malignancies
- gallbladder carcinoma
- pancreatic carcinoma
- primary peritoneal malignancy
- haematogenous spread
Clinical presentation
Isolated peritoneal metastases are usually asymptomatic. Peritoneal carcinomatosis may also be asymptomatic, but eventually most patients begin to report symptoms which can vary from uncomfortable to debilitating. Symptoms include 1:
- abdominal distention due to malignant ascities
- abnormal bowel motility, resulting
- nausea
/ bloating/bloating - intermittent pains
- bowel obstruction (most common from colorectal cancer metastases)
- nausea
Pathology
Malignant involvement of the peritoneal lining occurs via a number of routes, including 1:
- intraperitoneal seeding & direct invasion: most common
- haematogenous dissemination
- lymphatic dissemination: rare
Radiographic features
Although peritoneal metastases are visible on ultrasound, MRI and sometimes are implied on barium studies, CT is the most frequently used modality to investigate patients with suspected peritoneal metastases, or assess the resultant complications.
CT
Peritoneal metastases can range in appearance from invisible to multiple large masses, and historically CT can only detects 60-80% of peritoneal metastases later shown to be present at surgery, although more recent studies reported detection rates of 85-93% 1,3. Appearances include 1:
- thickening and enhancement of peritoneal reflections (especially if nodular)
- soft tissue nodules
- stranding and thickening of the omentum (omental cake)
- stranding an distortion of the small bowel mesentery
- ascites, especially if loculated
- calcifications 2 (particularly in cystadenocarcinoma of the ovary)
- nodular with non-calcified component are typical
- nodal calcification
Intraperitoneal contrast has been investigated as a way of improving sensitivity to the presence of small deposits, and may improve detection but has not been widely adopted 3.
Ultrasound
Malignant ascites may be anechoic or have low level echoes, and aids in the identification of deposits 1. Nodules are of intermediate echogenicity, hypo-echoichypoechoic compared to peritoneum, whereas infiltration of the omentum results in hyperechogenicity 1.
MRI
MRI can be very sensitive, probably more so than CT (85-90%) 1. Peritoneal metastases show up as increased enhancement (greater than liver), best seen after 5-10 minutes 1.
Treatment and prognosis
Peritoneal metastases per se are not locally treated, although systemic treatment may have some effect. Complications do however frequently require treatment for palliation:
-
bowel obstruction
-: bypass enterostomies may be required -
malignant ascites
-: repeated ascitic drainage
Differential diagnosis
Differential diagnosis depends on the dominant pattern. Peritoneal mesothelioma is very similar to peritoneal carcinomatosis, but usually no primary neoplasm is known.
Smooth thickening and enhancement of the peritoneum, with stranding of the omentum and mesentery may be seen in intra-abdominal sepsis.
Benign calcifications tend to be sheetlike, and nodal calcifications in these patients less common 2. A history of peritoneal dialysis or recent abdominal sepsis is usually easily obtained.
Another uncommon consideration would include peritoneal tuberculosis.
-<p><strong>Peritoneal metastases</strong> (also known as <strong>peritoneal carcinomatosis</strong> when extensive) are relatively common particularly in tumours of the abdomen and pelvis and generally imply a poor prognosis, often with a significant impact on palliation. </p>-<h4>Epidemiology</h4>-<p>The epidemiology of patients with peritoneal metastases mirrors that of affected patients. Common primaries include <sup>1-2</sup>: </p>-<ul>-<li><a title="Ovarian cancer " href="/articles/ovarian-tumours">ovarian cancer</a></li>-<li><a title="Gastric cancer" href="/articles/gastric-carcinoma">gastric cancer</a></li>-<li><a title="Colorectal cancer" href="/articles/colorectal-carcinoma">colorectal cancer</a></li>-<li><a title="appendiceal malignancies" href="/articles/appendiceal-malignancies">appendiceal malignancies</a></li>-<li><a title="Gallbladder carcinoma" href="/articles/gallbladder-adenocarcinoma">gallbladder carcinoma</a></li>-<li><a title="Pancreatic carcinoma" href="/articles/pancreatic-ductal-carcinoma">pancreatic carcinoma</a></li>-<li><a title="Primary peritoneal malignancy" href="/articles/primary-peritoneal-neoplasms">primary peritoneal malignancy</a></li>-<li>haematogenous spread-<ul>-<li><a title="Breast cancer" href="/articles/breast-neoplasms">breast cancer</a></li>-<li><a title="Lung cancer : general" href="/articles/bronchogenic-carcinoma">lung cancer</a></li>-<li><a title="Malignant melanoma" href="/articles/malignant-melanoma">malignant melanoma</a></li>- +<p><strong>Peritoneal metastases</strong> (also known as <strong>peritoneal carcinomatosis</strong> when extensive) are relatively common particularly in tumours of the abdomen and pelvis and generally imply a poor prognosis, often with a significant impact on palliation. </p><h4>Epidemiology</h4><p>The epidemiology of patients with peritoneal metastases mirrors that of affected patients. Common primaries include <sup>1-2</sup>: </p><ul>
- +<li><a href="/articles/ovarian-tumours">ovarian cancer</a></li>
- +<li><a href="/articles/gastric-carcinoma">gastric cancer</a></li>
- +<li><a href="/articles/colorectal-carcinoma">colorectal cancer</a></li>
- +<li><a href="/articles/appendiceal-malignancies">appendiceal malignancies</a></li>
- +<li><a href="/articles/gallbladder-adenocarcinoma">gallbladder carcinoma</a></li>
- +<li><a href="/articles/pancreatic-ductal-carcinoma">pancreatic carcinoma</a></li>
- +<li><a href="/articles/primary-peritoneal-neoplasms">primary peritoneal malignancy</a></li>
- +<li>haematogenous spread<ul>
- +<li><a href="/articles/breast-neoplasms">breast cancer</a></li>
- +<li><a href="/articles/lung-cancer-3">lung cancer</a></li>
- +<li><a href="/articles/malignant-melanoma">malignant melanoma</a></li>
-</ul><h4>Clinical presentation</h4>-<p>Isolated peritoneal metastases are usually asymptomatic. Peritoneal carcinomatosis may also be asymptomatic, but eventually most patients begin to report symptoms which can vary from uncomfortable to debilitating. Symptoms include <sup>1</sup>:</p>-<ul>-<li>abdominal distention due to malignant ascities</li>-<li>abnormal bowel motility, resulting-<ul>-<li>nausea / bloating</li>-<li>intermittent pains</li>- +</ul><h4>Clinical presentation</h4><p>Isolated peritoneal metastases are usually asymptomatic. Peritoneal carcinomatosis may also be asymptomatic, but eventually most patients begin to report symptoms which can vary from uncomfortable to debilitating. Symptoms include <sup>1</sup>:</p><ul>
- +<li>abdominal distention due to malignant ascities</li>
- +<li>abnormal bowel motility, resulting<ul>
- +<li>nausea/bloating</li>
- +<li>intermittent pains</li>
-</ul><h4>Pathology</h4>-<p>Malignant involvement of the peritoneal lining occurs via a number of routes, including <sup>1</sup>: </p>-<ul>-<li>intraperitoneal seeding & direct invasion: most common</li>-<li>haematogenous dissemination</li>- +</ul><h4>Pathology</h4><p>Malignant involvement of the peritoneal lining occurs via a number of routes, including <sup>1</sup>: </p><ul>
- +<li>intraperitoneal seeding & direct invasion: most common</li>
- +<li>haematogenous dissemination</li>
-</ul><h4>Radiographic features</h4>-<p>Although peritoneal metastases are visible on ultrasound, MRI and sometimes are implied on barium studies, CT is the most frequently used modality to investigate patients with suspected peritoneal metastases, or assess the resultant complications. </p>-<h5>CT</h5>-<p>Peritoneal metastases can range in appearance from invisible to multiple large masses, and historically CT can only detects 60-80% of peritoneal metastases later shown to be present at surgery, although more recent studies reported detection rates of 85-93% <sup>1,3</sup>. Appearances include <sup>1</sup>:</p>-<ul>-<li>thickening and enhancement of peritoneal reflections (especially if nodular) </li>-<li>soft tissue nodules</li>-<li>stranding and thickening of the omentum (<a title="Omental cake" href="/articles/omental_cake">omental cake</a>) </li>-<li>stranding an distortion of the small bowel mesentery </li>-<li>ascites, especially if loculated </li>-<li>calcifications <sup>2</sup> (particularly in <a title="Serous cystadenocarcinoma of the ovary" href="/articles/ovarian-serous-cystadenocarcinoma">cystadenocarcinoma of the ovary</a>)-<ul>-<li>nodular with non-calcified component are typical</li>- +</ul><h4>Radiographic features</h4><p>Although peritoneal metastases are visible on ultrasound, MRI and sometimes are implied on barium studies, CT is the most frequently used modality to investigate patients with suspected peritoneal metastases, or assess the resultant complications. </p><h5>CT</h5><p>Peritoneal metastases can range in appearance from invisible to multiple large masses, and historically CT can only detects 60-80% of peritoneal metastases later shown to be present at surgery, although more recent studies reported detection rates of 85-93% <sup>1,3</sup>. Appearances include <sup>1</sup>:</p><ul>
- +<li>thickening and enhancement of peritoneal reflections (especially if nodular) </li>
- +<li>soft tissue nodules</li>
- +<li>stranding and thickening of the omentum (<a href="/articles/omental-cake">omental cake</a>) </li>
- +<li>stranding an distortion of the small bowel mesentery </li>
- +<li>ascites, especially if loculated </li>
- +<li>calcifications <sup>2</sup> (particularly in <a href="/articles/ovarian-serous-cystadenocarcinoma">cystadenocarcinoma of the ovary</a>)<ul>
- +<li>nodular with non-calcified component are typical</li>
-</ul><p>Intraperitoneal contrast has been investigated as a way of improving sensitivity to the presence of small deposits, and may improve detection but has not been widely adopted <sup>3</sup>. </p>-<h5>Ultrasound</h5>-<p>Malignant ascites may be anechoic or have low level echoes, and aids in the identification of deposits <sup>1</sup>. Nodules are of intermediate echogenicity, hypo-echoic compared to peritoneum, whereas infiltration of the omentum results in hyperechogenicity <sup>1</sup>. </p>-<h5>MRI</h5>-<p>MRI can be very sensitive, probably more so than CT (85-90%) <sup>1</sup>. Peritoneal metastases show up as increased enhancement (greater than liver), best seen after 5-10 minutes <sup>1</sup>. </p>-<h4>Treatment and prognosis</h4>-<p>Peritoneal metastases <em>per se</em> are not locally treated, although systemic treatment may have some effect. Complications do however frequently require treatment for palliation: </p>-<ul>- +</ul><p>Intraperitoneal contrast has been investigated as a way of improving sensitivity to the presence of small deposits, and may improve detection but has not been widely adopted <sup>3</sup>. </p><h5>Ultrasound</h5><p>Malignant ascites may be anechoic or have low level echoes, and aids in the identification of deposits <sup>1</sup>. Nodules are of intermediate echogenicity, hypoechoic compared to peritoneum, whereas infiltration of the omentum results in hyperechogenicity <sup>1</sup>. </p><h5>MRI</h5><p>MRI can be very sensitive, probably more so than CT (85-90%) <sup>1</sup>. Peritoneal metastases show up as increased enhancement (greater than liver), best seen after 5-10 minutes <sup>1</sup>. </p><h4>Treatment and prognosis</h4><p>Peritoneal metastases <em>per se</em> are not locally treated, although systemic treatment may have some effect. Complications do however frequently require treatment for palliation: </p><ul>
-<a title="Bowel obstruction" href="/articles/bowel-obstruction">bowel obstruction</a> - bypass enterostomies may be required</li>- +<a href="/articles/bowel-obstruction">bowel obstruction</a>: bypass enterostomies may be required</li>
-<a title="malignant ascites" href="/articles/malignant-ascites">malignant ascites</a> - repeated ascitic drainage</li>-</ul><h4>Differential diagnosis</h4>-<p>Differential diagnosis depends on the dominant pattern. <a title="Peritoneal mesothelioma" href="/articles/peritoneal-mesothelioma">Peritoneal mesothelioma</a> is very similar to peritoneal carcinomatosis, but usually no primary neoplasm is known.</p>-<p>Smooth thickening and enhancement of the peritoneum, with stranding of the omentum and mesentery may be seen in intra-abdominal sepsis. </p>-<p>Benign calcifications tend to be sheetlike, and nodal calcifications in these patients less common <sup>2</sup>. A history of peritoneal dialysis or recent abdominal sepsis is usually easily obtained. </p>-<p>Another uncommon consideration would include <a title="Tuberculous peritonitis" href="/articles/tuberculous-peritonitis">peritoneal tuberculosis</a>.</p>- +<a href="/articles/malignant-ascites">malignant ascites</a>: repeated ascitic drainage</li>
- +</ul><h4>Differential diagnosis</h4><p>Differential diagnosis depends on the dominant pattern. <a href="/articles/peritoneal-mesothelioma">Peritoneal mesothelioma</a> is very similar to peritoneal carcinomatosis, but usually no primary neoplasm is known.</p><p>Smooth thickening and enhancement of the peritoneum, with stranding of the omentum and mesentery may be seen in intra-abdominal sepsis. </p><p>Benign calcifications tend to be sheetlike, and nodal calcifications in these patients less common <sup>2</sup>. A history of peritoneal dialysis or recent abdominal sepsis is usually easily obtained. </p><p>Another uncommon consideration would include <a href="/articles/tuberculous-peritonitis">peritoneal tuberculosis</a>.</p>
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