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A 67-year-old man develops peritoneal carcinomatosis from gastric carcinoma
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A 67-year-old man in relatively good health presented to the ED with abdominal pain, nausea and vomiting.
His medical history was significant for hypertension, and he underwent a diverting loop colostomy about 6 months before the current presentation for a perforated diverticulitis. A colonoscopy and CT scan of the abdomen performed at the time of the initial surgery did not show any evidence of malignancy.
He was taking the prescribed bowel preparation for the planned colostomy reversal when he developed the above mentioned symptoms. He also complained of abdominal discomfort, indigestion and a general sense of feeling sick.
Physical exam and blood work were unremarkable. He was suspected to have bowel obstruction, and a CT scan of the abdomen and pelvis with contrast was obtained (see figures).
CT revealed a high-grade small bowel obstruction with collapse of the distal small bowel and the colon. Also noted were thickening of the gastroesophageal junction, suggesting the possibility of a primary lesion in the gastroesophageal junction, and confluent lymphadenopathy in the supra celiac area and above the left adrenal gland.
Figure 1. Upright abdominal radiograph (left) and CT scout image (right) demonstrate a high-grade small bowel obstruction.
Source: Ghesani M
There was a nodule in the anterior omentum superior to the right of the umbilicus and in the right supravesical fossa and lower left paracolic gutter, raising the question of metastatic implants.
Figure 2. Axial CT image demonstrates an abrupt small bowel transition point in the pelvis at an area of extensive nodular soft tissue implants (arrows). End-colostomy is noted in the left lower abdomen.
He underwent a laparotomy with lysis of adhesions and a palliative ileocolostomy with small bowel anastomosis in the hope of overcoming the severe bowel obstruction. At surgery, he was found to have extensive peritoneal implants with small bowel loops caked into the pelvis with tumor. Biopsy of the tissue revealed poorly differentiated adenocarcinoma, and further surgery was aborted because he was not deemed an appropriate candidate for cytoreduction given extensive peritoneal disease.
After surgery, he was started on chemotherapy with cisplatin and irinotecan. He received two cycles of chemotherapy and had a few admissions to the hospital for various reasons, including diarrhea, infections and worsening symptoms of bowel obstruction. Repeat CT scan of the abdomen and pelvis again showed evidence of extensive progression of the disease despite chemotherapy. He was enrolled into palliative care hospice about 2 months after the initial diagnosis.
Discussion
Peritoneal carcinomatosis is the most common secondary tumor affecting the peritoneal cavity. It occurs most commonly with the cancers of the gastrointestinal tract and ovaries. Common gastrointestinal tumors include stomach, colon and appendix, although cancers from other gastrointestinal organs — such as the liver, gallbladder and pancreas — also have been implicated.
Figure 3. Axial CT (left) and coronal reformatted CT (right) images demonstrate lymphadenopathy, as well as focal thickening at the gastroesophageal junction (arrows) suspicious for the malignant primary lesion.
Extra-gastrointestinal cancers that commonly metastasize to the peritoneum and cause peritoneal carcinomatosis include ovary, breast, lung and uterus cancers.
Figure 4. Nodule in the anterior omentum adjacent to the umbilicus (arrow). Multiple distended loops of small bowel are well demonstrated.
Involvement of the peritoneum occurs by intraperitoneal seeding, direct invasion, hematogenous spread or lymphatic dissemination. Common clinical manifestations include nausea, vomiting, abdominal pain and bowel obstruction, and they could signify advanced disease.
Characteristic pathologic features of peritoneal carcinomatosis include tumor nodules studding the peritoneal surfaces. As the tumor invades the peritoneal tissues, fibrotic response may occur, resulting in severe fibrosis and formation of classic omental caking. This can result in encasement of the bowel loops along with omentum, which can lead to severe bowel obstruction. Histologically, these adenocarcinomas are commonly characterized by abundant mucin or by signet ring cell morphology.
Imaging modalities
The most commonly employed imaging modalities to evaluate peritoneal carcinomatosis are CT scan, MRI and PET/CT scans. CT scan is the usual initial imaging modality used because it is the imaging of choice for evaluating patients with generalized abdominal disorders, and often those with peritoneal carcinomatosis usually present with vague abdominal symptoms.
CT findings of peritoneal carcinomatosis include discrete nodules on the peritoneum, infiltrative masses and straightening of the mesenteric vasculature producing a pleated appearance secondary to the fibrosis and tumor infiltration. Small bowel obstruction and ascites are commonly associated with peritoneal carcinomatosis and usually are appreciable on the CT.
MRI provides superior soft tissue contrast, helping in better delineation, detection and prediction of the tumor burden in peritoneal carcinomatosis. PET/CT provides metabolic information, which enables the identification of malignant lesions as hypermetabolic nodules/masses secondary to increased glucose consumption by the tumor tissue. In addition, PET/CT also is helpful in identifying other sites of metastatic disease.
The role of HIPEC
Traditionally, peritoneal carcinomatosis has been considered a terminal condition and palliative treatment was offered. However, with the advent of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC), there is a trend toward improved survival.
Sugarbaker’s peritoneal carcinomatosis index is commonly employed to assess the tumor burden. The index ranges from 0 to 39, and scores below 20 are associated with favorable prognosis. Cytoreduction consists of resection of the peritoneum (parietal and visceral) of all of the areas affected by tumor, omentectomy and resections of the other involved organs, as appropriate, with the goal of leaving minimal residual tumor (usually less than 1 cm to 2 cm).
HIPEC involves delivering the chemotherapy into the peritoneal cavity immediately after surgery at high temperatures (40°C-43°C). The combination of hyperthermia and chemotherapy is considered to be more effective in tumor burden reduction. The most common agents employed for HIPEC are cisplatin and mitomycin C.
The incidence of peritoneal carcinomatosis in gastric cancer is about 10% to 50%, especially when serosa is involved.
Gill and colleagues published an extensive literature review about the role of HIPEC in patients with peritoneal carcinomatosis in gastric cancer. They reported a median survival of 15 months vs. 3 months among patients who received best supportive care. The role of systemic chemotherapy in patients with peritoneal carcinomatosis in gastric cancer is not clearly defined, but there is some evidence to suggest an improvement in OS to about 7 to 10 months.
HIPEC is evolving as a new standard of care for patients with peritoneal carcinomatosis, and it has clearly shown to have survival advantage over traditional approaches.
References:
- Brücher BL. Cancer Invest. 2012;30:209-224.
- Gill RS. J Surg Oncol. 2011;104:692-698.
- Klumpp BD. Abdom Imaging. 2012;doi:10.1007/s00261-012-9881-7.
- Levy AD. Radiographics. 2009;29:347-373.
For more information:
- Munir Ghesani, MD, is an attending radiologist at St. Luke’s-Roosevelt Hospital Center and Beth Israel Medical Center, an associate clinical professor of radiology at Columbia University College of Physicians and Surgeons, and a HemOnc Today section editor. Rangaswamy Chintapatla, MD, is a fellow in hematology and oncology at St. Luke’s-Roosevelt Hospital Center. Michael Thomas Starc, MD, is a radiology resident at St. Luke’s-Roosevelt Hospital Center. Gabriel Sara, MD, is an attending in hematology/oncology at St. Luke’s-Roosevelt Hospital Center. Disclosure: Drs. Ghesani, Chintapatla, Starc and Sara report no relevant financial disclosures.