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1 Case presentation 新光醫院 核子醫學科 葉力豪2010/3/13. 2 Case 1: History 70 y/o female 70 y/o female PH: PH: HBV & HCV carrier HBV & HCV carrier DM DM CC: Lower.

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Presentation on theme: "1 Case presentation 新光醫院 核子醫學科 葉力豪2010/3/13. 2 Case 1: History 70 y/o female 70 y/o female PH: PH: HBV & HCV carrier HBV & HCV carrier DM DM CC: Lower."— Presentation transcript:

1 1 Case presentation 新光醫院 核子醫學科 葉力豪2010/3/13

2 2 Case 1: History 70 y/o female 70 y/o female PH: PH: HBV & HCV carrier HBV & HCV carrier DM DM CC: Lower abdominal pain for one month CC: Lower abdominal pain for one month Dull and intermittent Dull and intermittent No aggravating or relieving factors No aggravating or relieving factors

3 3 Case 1: History Gynecology sonography (2008/9/24): Gynecology sonography (2008/9/24): WNL, Bil. Adnexa: invisible WNL, Bil. Adnexa: invisible Colonoscopy (2008/9/26): Colonoscopy (2008/9/26): internal hemorrhoid internal hemorrhoid U/A: normal U/A: normal CT of abdomen and pelvis (2009/10/29): CT of abdomen and pelvis (2009/10/29):

4 4 Omental thickening (Omental cake) nodularity Peritoneal carcinomatosis

5 5 Omental thickening (Omental cake) nodularity

6 6 Case 1: History Tumor marker (2008/10/31): Tumor marker (2008/10/31): CEA: 0.7 (0~5) CEA: 0.7 (0~5) CA125: 93.91 (0~35) CA125: 93.91 (0~35) CA19-9: 7.27 (0~27) CA19-9: 7.27 (0~27) Gynecology sonography (2008/11/5): Gynecology sonography (2008/11/5): Bilateral adnexa: invisible Bilateral adnexa: invisible

7 7 FDG-PET/CT (2008/11/6)

8 8 Omental thickening

9 9

10 10 Omental thickening

11 11 Case 1: History Impression: Primary peritoneal carcinoma Impression: Primary peritoneal carcinoma Laparotomy (2008/11/13): Laparotomy (2008/11/13): Large omental cake adhesion to anterior peritoneal layer Large omental cake adhesion to anterior peritoneal layer Some ascites < 50 cc Some ascites < 50 cc Nodularity over whole peritoneum, esp. cul-de-sac, bilateral pelvic cavity and anterior bladder wall Nodularity over whole peritoneum, esp. cul-de-sac, bilateral pelvic cavity and anterior bladder wall Bilateral adnexa: grossly normal, about 2x1cm(Rt) & 1.5x1cm(Lt) Bilateral adnexa: grossly normal, about 2x1cm(Rt) & 1.5x1cm(Lt)

12 12 Case 1: History Operative procedures: Operative procedures: Bil. salpingo-oophorectomy + omentectomy + retroperitoneal tumor biopsy + washing cytology Bil. salpingo-oophorectomy + omentectomy + retroperitoneal tumor biopsy + washing cytology Pathology: Pathology: Left ovary: Serous cystadenocarcinoma Left ovary: Serous cystadenocarcinoma Right ovary: Negative for malignancy Right ovary: Negative for malignancy Omentum metastases (>2cm, T3c, Stage IIIC) Omentum metastases (>2cm, T3c, Stage IIIC)

13 13 Case 2: History 49 y/o female 49 y/o female Past History: Past History: Asthma Asthma Hyperthyroidism Hyperthyroidism Major depression Major depression G4P2, Perimenopause G4P2, Perimenopause Appendicitis s/p appendectomy Appendicitis s/p appendectomy Bilateral ovarian chocolate cysts s/p operation Bilateral ovarian chocolate cysts s/p operation

14 14 Case 2: History Chief Complaint (2008/12): Chief Complaint (2008/12): Lower abdominal pain Lower abdominal pain CA-125: 92.3 (normal < 35) CA-125: 92.3 (normal < 35)

15 15 Case 2: History Gyn echo (2008/12/26) : Gyn echo (2008/12/26) : Uterine myoma Uterine myoma R’t ovary: 2.46 x 1.59 cm R’t ovary: 2.46 x 1.59 cm Suspicious left ovarian cyst: 2.68 x 1.66cm Suspicious left ovarian cyst: 2.68 x 1.66cm

16 16 Case 2: History 2009/4/29: 2009/4/29: CA-125: 93.71 U/ml (normal < 35) CA-125: 93.71 U/ml (normal < 35) CA-153: 64.08 U/ml (normal < 30) CA-153: 64.08 U/ml (normal < 30) Breast echo: normal Breast echo: normal Gyn echo: Gyn echo: R’t ovary : 1.94 x 1.46 cm R’t ovary : 1.94 x 1.46 cm L’t ovary : unremarkable L’t ovary : unremarkable Adenomyosis of uterus Adenomyosis of uterus

17 17 2009/6/23

18 18 Omental thickening

19 19

20 20 Omental thickening Cul-de-sac

21 21 Cul-de-sac Omental thickening

22 22 Omental thickening

23 23 Case 2: History Operation at 和信醫院 : Operation at 和信醫院 : Total abdominal hysterectomy + bilateral salpingo-oophorectomy + pelvic LN dissection + Cul-de-sac & peritoneal tumor resection + omentectomy Total abdominal hysterectomy + bilateral salpingo-oophorectomy + pelvic LN dissection + Cul-de-sac & peritoneal tumor resection + omentectomy

24 24 Case 2: History Patholgy: Patholgy: Bil. Ovary & fallopian tube: Bil. Ovary & fallopian tube: High grade papillary serous carcinoma High grade papillary serous carcinoma R’t ovary: 2.5 x 2 x 1.5 cm R’t ovary: 2.5 x 2 x 1.5 cm L’t ovary : 2.5 x 1.1 x 0.5 cm L’t ovary : 2.5 x 1.1 x 0.5 cm

25 25 Case 2: History Cul-de-sac, peritoneum, omentum: Cul-de-sac, peritoneum, omentum: High grade papillary serous carcinoma High grade papillary serous carcinoma Serosal surface of the uterus, pelvic LNs: Serosal surface of the uterus, pelvic LNs: metastatic adenocarcinoma (N1 stage  Stage metastatic adenocarcinoma (N1 stage  Stage IIIC at least) IIIC at least) Uterus: Uterus: four myoma (measuring up to 3.4 cm) four myoma (measuring up to 3.4 cm)

26 26 Discussion

27 27 Peritoneal Carcinomatosis Definition: Definition: Extensive, or very widespread, metastasis of cancerous tumors onto the inside surfaces (peritoneum) of the abdomen.

28 28 Peritoneal Carcinomatosis Occurs commonly with abdominopelvic tumors Occurs commonly with abdominopelvic tumors Most common tumors: Most common tumors: Ovarian carcinoma (female) Ovarian carcinoma (female) Gastric cancer Gastric cancer Pancreas cancer Pancreas cancer Colon cancer Colon cancer

29 29 Peritoneal Carcinomatosis Ascites Ascites Soft tissue masses or thickening of the parietal peritoneum Soft tissue masses or thickening of the parietal peritoneum Omental thickening (omental cake) Omental thickening (omental cake) Tumor nodules & enlarged LNs in the mesentery Tumor nodules & enlarged LNs in the mesentery Thickening & nodularity of the bowel wall Thickening & nodularity of the bowel wall

30 30 Anatomy of peritoneum From: http://www.bala6y.org/vb/showthread.php?t=11687

31 31 Abdom Imaging (2009) 34: 391-402 Pathways of ascites & sites of tumor seeding

32 32 Bil. Ovarian cancer with peritoneal seeding

33 33 Peritoneal seeding to paracolic gutters & greater omentum Paracolic gutter Omental thickening

34 34 Peritoneal seeding to Morison’s pouch Morison’s pouch

35 35 Peritoneal seeding to falciform ligment

36 36 Peritoneal seeding to subdiaphragmatic surface

37 37 Rectal cancer with abdominal wall and bowel loop involvement

38 38 Mesenteric neoplatic implants with bowel loop involvement Abdom Imaging (2009) 34: 391-402

39 39 Mesenteric neoplastic nodule Abdom Imaging (2009) 34: 391-402

40 40 Perirectal ovarian carcinoma neoplastic implants Abdom Imaging (2009) 34: 391-402

41 41 Ovarian carcinoma- cystic peritoneal neoplastic implant Abdom Imaging (2009) 34: 391-402

42 42 Neoplastic nodule in the adipose tissue of the hernia sac Abdom Imaging (2009) 34: 391-402

43 43 FDG-PET/CT in peritoneal carcinomatosis False negative: False negative: Cystic lesions Cystic lesions Small volume disease or miliaric seeding Small volume disease or miliaric seeding False postive: False postive: Bowel activity Bowel activity Focal retained activity in ureters and urinary bladder Focal retained activity in ureters and urinary bladder Abdom Imaging (2009) 34: 391-402

44 44 Peritoneal Carcinomatosis D.D.: D.D.: Lymphoma Lymphoma Primary peritoneal mesothelioma Primary peritoneal mesothelioma Gastrointestinal stromal tumors Gastrointestinal stromal tumors Peritoneal tuberculosis Peritoneal tuberculosis Indian J Radiol Imaging 2010;20:58-62

45 45 Normal-sized ovarian carcinoma syndrome Diffuse metastatic disease of the peritoneal cavity. Diffuse metastatic disease of the peritoneal cavity. Ovaries are macroscopically normal (<4cm) or only have fine nodularities on the external surface. Ovaries are macroscopically normal (<4cm) or only have fine nodularities on the external surface. Obstet Gynecol. 1989;73(5 Pt 1):786-92.

46 46 Normal-sized ovarian carcinoma syndrome Including: Including: Mesothelioma Mesothelioma Primary peritoneal carcinoma Primary peritoneal carcinoma Primary ovarian carcinoma ( Serous surface papillary carcinoma of ovary, ) Primary ovarian carcinoma ( Serous surface papillary carcinoma of ovary, Papillary serous carcinoma in ovaries of normal size ) Metastatic tumor from another primary origin Metastatic tumor from another primary origin Obstet Gynecol. 1989;73(5 Pt 1):786-92.

47 47 Serous surface papillary carcinoma of ovary Originating from the surface epithelium of the ovary Originating from the surface epithelium of the ovary Absence of involvement or only microscopic involvement of the ovarian parenchyma. Absence of involvement or only microscopic involvement of the ovarian parenchyma. A distinct subtype of serous papillary carcinoma of the ovary A distinct subtype of serous papillary carcinoma of the ovary Extensive peritoneal spread Extensive peritoneal spread Acta Radiologica 38 (1997) 847-849

48 48 Serous surface papillary carcinoma of ovary Imaging findings (CT, US, MRI): Imaging findings (CT, US, MRI): Diffuse nodularities along the serosal surface of the ovaries, uterus and peritoneum without ovarian mass. Diffuse nodularities along the serosal surface of the ovaries, uterus and peritoneum without ovarian mass. The nodular lesions obliterated the outer margin of uterus and ovaries. The nodular lesions obliterated the outer margin of uterus and ovaries. Acta Radiologica 38 (1997) 847-849

49 49 Omental thickening (Omental cake) nodularity

50 50 Serous surface papillary carcinoma of ovary AJR 2004;183:1721–1724 Elevated CA-125 in all pts (most > 200 U/ml) Elevated CA-125 in all pts (most > 200 U/ml)

51 51 CA-125 & Ovarian Cancer The average reported sensitivities for ovarian cancer: The average reported sensitivities for ovarian cancer: 50% for stage I 50% for stage I 90% for stage II or higher disease 90% for stage II or higher disease Varies according to histology Varies according to histology Specificity of CA 125 is limited. Specificity of CA 125 is limited. Rarely > 100~200 U/ml in benign conditions. Rarely > 100~200 U/ml in benign conditions. From UpToDate; Epithelial ovarian cancer : Clinical manifestations, diagnostic evaluation, staging, and histopathology

52 52

53 53 CA-125 & Ovarian Cancer Not a useful diagnostic test in premenopausal women, especially at low positive levels (warning if > 200 U/ml). Not a useful diagnostic test in premenopausal women, especially at low positive levels (warning if > 200 U/ml). It is more useful in postmenopausal women, in whom the positive predictive value for malignancy is 97 %. It is more useful in postmenopausal women, in whom the positive predictive value for malignancy is 97 %.

54 54 CA-125 & Ovarian Cancer High preoperative CA-125 levels correlate with: High preoperative CA-125 levels correlate with: Advanced stage (III or IV) Advanced stage (III or IV) High grade disease High grade disease Serous histology Serous histology The presence of ascites The presence of ascites

55 55 CA-125 & Ovarian Cancer Not a reliable predictor of the likelihood of optimal cytoreduction. Not a reliable predictor of the likelihood of optimal cytoreduction. Baseline measurement is useful in evaluating the success of subsequent treatment. Baseline measurement is useful in evaluating the success of subsequent treatment.

56 56 CA 125 & Ovarian Cancer A pelvic mass suspicious for malignancy if: A pelvic mass suspicious for malignancy if: Ascites Ascites Nodularity/fixation Nodularity/fixation Evidence of metastases Evidence of metastases A First degree relative with ovarian or brest cancer A First degree relative with ovarian or brest cancer Elevated CA-125 level (normal < 35) Elevated CA-125 level (normal < 35) Any abnormal in the postmenopausal Any abnormal in the postmenopausal A level > 200 U/ml in the premenopausal A level > 200 U/ml in the premenopausal American College of Obstetricians and Gynecologists

57 57 Conclusion Peritoneal carcinomatosis occurs commonly with abdominopelvic tumors. Peritoneal carcinomatosis occurs commonly with abdominopelvic tumors. FDG-PET/CT has the potential to improve detection of peritoneal carcinomatosis. But there are limits. FDG-PET/CT has the potential to improve detection of peritoneal carcinomatosis. But there are limits. In normal-sized ovarian carcinoma syndrome, peritoneal carcinomatosis is noted, despite of normal size of ovaries. In normal-sized ovarian carcinoma syndrome, peritoneal carcinomatosis is noted, despite of normal size of ovaries.

58 58 Conclusion Elevation serum CA-125 ( any abnormal in the postmenopausal, and > 200 U/ml in the premenopausal) can help in the diagnosis of ovarian cancer. Elevation serum CA-125 ( any abnormal in the postmenopausal, and > 200 U/ml in the premenopausal) can help in the diagnosis of ovarian cancer.

59 59 Thank You


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