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)
nodularity

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)
nodularity

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