- Open Access
Detection of peritoneal metastases
- Jeremiah C. Healy1
© International Cancer Imaging Society 2001
- Published: 5 May 2015
Direct spread along peritoneal ligaments, mesenteries and omenta to non-contiguous organs
Intraperitoneal seeding via ascitic fluid
Embolic haematogenous spread.
Before the introduction of cross-sectional imaging, the peritoneum and its reflections could only be imaged with difficulty, often requiring invasive techniques. Computed tomography and to a lesser extent sonography and MR imaging allow us to examine the complex anatomy of the peritoneal cavity accurately, which is the key to understanding the spread of peritoneal metastases. This article reviews the detection of peritoneal metastases.
- Peritoneal Metastasis
- Great Omentum
- Peritoneal Reflection
- Pseudomyxoma Peritonei
- Transverse Mesocolon
Metastatic disease is the most common malignant process involving the peritoneum. Metastases are usually from intra-abdominal primary neoplasms, such as carcinoma of the stomach, colon, ovary and pancreas, or from intraabdominal lymphoma.
Prior to the advent of CT, peritoneal metastases were not radiographically detectable until late in the disease, when they displaced adjacent organs, caused intestinal obstruction, or produced radiological signs due to massive ascites on plain films. CT can identify peritoneal metastases as small as a few millimetres in size and also identify very small volumes of ascites. This information is essential in staging tumours, assessing resectability, monitoring response, and identifying recurrence.
The imaging appearances of metastatic peritoneal disease are in part determined by the tumour type itself, but predominantly by the mode of peritoneal dissemination.
CT is considered the best imaging procedure for the evaluation of patients with known or suspected peritoneal metastases. The use of intraperitoneal positive contrast and pneumoperitoneum with CT has been suggested to improve the detection of small peritoneal metastases but these techniques do not routinely opacify all the peritoneal recesses[2–4]. These methods are more interventional and time consuming and consequently are not widely used.
Recent reports describe the use of MR imaging in identifying peritoneal implants[5,6]. MR imaging of the peritoneum has been most successfully achieved using fat saturated T1-weighted sequences following intravenous gadolinium. The inferior spatial resolution, the problems of motion artefact related to respiration and bowel peristalsis, and the lack of an effective bowel opacification agent makes MR imaging a generally less accurate test than CT for the identification of peritoneal metastases. However a recent report from the Radiological Diagnostic Oncology Group reviewed the performance of ultrasound, MR imaging, and CT for diagnosing and staging ovarian cancer. They found in a group of 280 patients that CT and MR imaging had similar accuracy for staging advanced ovarian cancer. Both were much more accurate than ultrasound.
This study used state-of-the-art MR techniques with phased array body coils, breath-hold sequences which included T1-weighted images with fat saturation before and after intravenous gadolinium chelate.
Ultrasound will demonstrate superficial peritoneal and omental metastases as small as 2 to 3 mm in the presence of ascites. However, centrally located deposits, for example in the small mesentery, will not be visualized because of the acoustic impedance of bowel gas and fat[9, 10]. Ultrasound is useful for image-guided aspiration/drainage of ascites and the biopsy of superficial peritoneal deposits.
Barium studies provide only indirect signs of peritoneal and mesenteric disease and thus are not used as the first line of investigation. The typical features of mesenteric or omental infiltration by metastases include: mass effect on adjacent bowel; nodularity, spiculation or tethering of adjacent mucosal folds or haustra; sacculation of the uninvolved contralateral border; or circumferential narrowing of the bowel lumen. These changes most frequently occur with contiguous involvement of the transverse colon or stomach. Barium studies will occasionally reveal abnormalities related to peritoneal metastases not clearly demonstrated on CT.
Scintigraphy has also been used to identify peritoneal metastases but is not very sensitive or specific and needs CT for anatomical location.
directly along peritoneal ligaments, mesenteries and omenta to non-contiguous structures;
intraperitoneal seeding via the flow of ascitic fluid;
embolic haematogenous spread.
Eight ligaments — the right and left coronary, falciform, hepatoduodenal, duodenocolic, gastros-plenic, splenorenal, and phrenicocolic ligaments;
Four mesenteries — the small bowel mesentery, the transverse mesocolon, the sigmoid meso-colon, and the mesoappendix;
Neoplasms of the colon, stomach, and pancreas often use the transverse mesocolon and greater omentum as conduits for spread (Fig. 2b). Direct invasion is well demonstrated on CT as increased density or discrete soft tissue masses in the fat of the transverse mesocolon. The right hand margin of the transverse mesocolon is thickened as the duodenocolic ligament providing a direct route for extension of colonic cancer from the hepatic flexure to the duodenum[20.21].
In the left upper quadrant the gastrosplenic ligament, continuous with the greater omentum, extends from the greater curve of the stomach to the spleen. It can be involved by extramural spread from gastric cancer and explains the association of splenic abscess with this tumour, often seen on CT.
Intraperitoneal fluid is constantly circulating throughout the abdomen influenced by gravity and negative intraabdominal pressure, produced beneath the diaphragm during respiration. It allows transcoelomic dissemination of malignant cells. Their deposition, fixation and growth are encouraged in particular sites due to relative stasis of ascitic fluid.
The most common tumours to spread in this fashion include ovarian cancer in females and malignancies of the gastrointestinal tract in males, especially cancer of the stomach, colon, and pancreas.
the pelvis, especially the pouch of Douglas;
the right lower quadrant at the inferior junction of the small bowel mesentery;
the superior aspect of the sigmoid mesocolon;
the right paracolic gutter. Spread of deposits to the right subhepatic and subphrenic spaces is also frequently seen, especially in ovarian cancer. Almost 90% of patients with ovarian cancer have peritoneal implants at post mortem and 60–70% have ascites[24, 25].
The small bowel mesentery and greater omentum are frequently involved by intraperitoneal seeding of metastases. Four patterns of involvement are described on CT: round masses, ‘cake-like’ masses (Fig. 3b), ill-defined masses, and stellate masses.
Irregular, ‘cake-like’ masses are seen most often with ovarian cancer. Densely calcified omental ‘cake’ has been reported in metastatic serous cystadenocarcinoma. The stellate pattern of mesenteric or omental mass is seen with pancreatic, colonic and breast cancer and results from diffuse infiltration, causing thickening and rigidity of the perivascular bundles. Widespread peritoneal metastases, including omental infiltration is a rare consequence of retroperitoneal malignancy, such as renal cell carcinoma (Fig. 3c, 5c).
Metastatic deposits to the ovaries from gastric or colonic primary tumours in association with ascites and other peritoneal deposits are a well-recognized entity. These tumours, known as ‘Krukenberg’ tumours, are presumed to be a consequence of transcoelomic spread and are clearly visualized on CT.
The abdomen is a common site for haematogenous metastases from both intra-abdominal and extra-abdominal primary tumours. The tumour emboli spread via the mesenteric arteries to deposit on the antimesenteric border of the bowel in the smallest arterial branches, where they grow into mural nodules.
The most common tumours that metastasise embolically to bowel and the peritoneal reflections are melanoma, breast and lung cancer. These metastases often occur several years after treatment of the primary neoplasm. Occasionally bowel obstruction or intussusception, as a consequence of embolic metastases, may be the first manifestation of an occult malignancy.
Whilst most imaging appearances are non-specific and can also be mimicked by primary peritoneal malignancy and peritoneal inflammatory conditions, some peritoneal metastases have characteristic appearances. Understanding the complex peritoneal anatomy and the methods of spread may suggest the primary malignancy. The CT identification of peritoneal metastases has been correlated with second look laparotomy. The specificity of CT for the diagnosis of peritoneal metastases is high ranging from 85–87%, however its sensitivity is low, ranging from 42–47%[45,46]. Laparoscopy has also demonstrated a significant incidence of peritoneal metastases in patients with a negative CT scan. Notably if ascites is present but no peritoneal deposits are seen on CT, laparoscopy demonstrated deposits in 75% of cases. At present CT remains the most useful imaging modality but recent MR technical developments allow similar accuracy in staging advanced disease.
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