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

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Presentation on theme: "Case presentation 新光醫院 核子醫學科 葉力豪 2010/3/13."— Presentation transcript:

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 PH:
HBV & HCV carrier DM CC: Lower abdominal pain for one month Dull and intermittent No aggravating or relieving factors

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

4 Peritoneal carcinomatosis
Omental thickening (Omental cake) nodularity

5 Omental thickening (Omental cake)

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

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

8 Omental thickening

9 Omental thickening

10 Omental thickening

11 Case 1: History Impression: Primary peritoneal carcinoma
Laparotomy (2008/11/13): Large omental cake adhesion to anterior peritoneal layer Some ascites < 50 cc 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) Suggest laparotomy ny GYN DOCTOR Impression : primary peritoneal carcinoma

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

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

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

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

16 Case 2: History 2009/4/29: CA-125: 93.71 U/ml (normal < 35)
Breast echo: normal Gyn echo: R’t ovary : 1.94 x 1.46 cm L’t ovary : unremarkable Adenomyosis of uterus 健檢 PES, colonoscopy, breast echo, abd echo, Gyn echo, CTA, low dose CT

17 2009/6/23

18 Omental thickening Omental thickening


20 Omental thickening Cul-de-sac

21 Cul-de-sac Omental thickening

22 Omental thickening

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

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

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

26 Discussion

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

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

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

30 Anatomy of peritoneum From:

31 Pathways of ascites & sites of tumor seeding
Greater Abdom Imaging (2009) 34:

32 Bil. Ovarian cancer with peritoneal seeding

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

34 Peritoneal seeding to Morison’s pouch

35 Peritoneal seeding to falciform ligment

36 Peritoneal seeding to subdiaphragmatic surface

37 Rectal cancer with abdominal wall and bowel loop involvement
53 y/o male Rectal cancer s/p LAR and CCRT

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

39 Mesenteric neoplastic nodule
Abdom Imaging (2009) 34:

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

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

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

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

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

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

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

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

48 Serous surface papillary carcinoma of ovary
Imaging findings (CT, US, MRI): 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. Acta Radiologica 38 (1997)

49 Omental thickening (Omental cake)

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

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


53 CA-125 & Ovarian Cancer 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 %.

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

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

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

57 Conclusion Peritoneal carcinomatosis occurs commonly with abdominopelvic tumors. 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.

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.

59 Thank You

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