EURORAD ESR

Case 14308

Cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy of peritoneal carcinomatosis: pre- and post-surgical CT imaging

Author(s)
Tonolini Massimo, M.D.

"Luigi Sacco" University Hospital, Radiology Department; Via G.B. Grassi 74 20157 Milan, Italy; Email:mtonolini@sirm.org
 
Patient
female, 75 year(s)
 
 
  • Figure 1
    Initial contrast-enhanced multidetector CT before intravenous chemotherapy
     

    Compared to previous studies (not shown), CT showed absence of hepatosplenic lesions, a left-sided 4-cm solid mass (thick arrows) and minimal ascites (+) in the pelvis.

     
    Area of Interest: Abdomen; Imaging Technique: CT; Procedure: Staging; Special Focus: Neoplasia;

    Compared to previous studies (not shown), CT showed absence of hepatosplenic lesions, a left-sided 4-cm solid mass (thick arrows) and minimal ascites (+) in the pelvis.

     
    Area of Interest: Abdomen; Imaging Technique: CT; Procedure: Staging; Special Focus: Neoplasia;

    Additionally, appearance of hazy infiltration (*) of the mesocolic omental fat was noted.

     
    Area of Interest: Abdomen; Imaging Technique: CT; Procedure: Staging; Special Focus: Neoplasia;

    Additionally, appearance of hazy infiltration (*) of the mesocolic omental fat was noted.

     
    Area of Interest: Abdomen; Imaging Technique: CT; Procedure: Staging; Special Focus: Neoplasia;
     
     
  • Figure 2
    Post-intravenous chemotherapy follow-up contrast-enhanced CT
     

    Repeated CT showed multi-compartmental ascites (+), increase of omental fat neoplastic infiltration (*) and of pelvic neoplastic recurrence (thick arrows), appearance of two 1.5 cm solid peritoneal nodules in...

     
    Area of Interest: Abdomen; Imaging Technique: CT; Procedure: Staging; Special Focus: Neoplasia;

    Repeated CT showed multi-compartmental ascites (+), increase of omental fat neoplastic infiltration (*).

     
    Area of Interest: Abdomen; Imaging Technique: CT; Procedure: Staging; Special Focus: Neoplasia;

    Repeated CT showed multi-compartmental ascites (+), increase of omental fat neoplastic infiltration (*) and of pelvic neoplastic recurrence (thick arrows), the latter measuring approximately 8x4.5 cm.

     
    Area of Interest: Abdomen; Imaging Technique: CT; Procedure: Staging; Special Focus: Neoplasia;

    Repeated CT showed multi-compartmental ascites (+), and of pelvic neoplastic recurrence (thick arrows), the latter measuring approximately 8x4.5 cm.

     
    Area of Interest: Abdomen; Imaging Technique: CT; Procedure: Staging; Special Focus: Neoplasia;

    Repeated CT showed multi-compartmental ascites (+), increase of omental fat neoplastic infiltration (*), and appearance of two 1.5 cm solid peritoneal nodules in epigastrium (thin arrows).

     
    Area of Interest: Abdomen; Imaging Technique: CT; Procedure: Staging; Special Focus: Neoplasia;

    Two additional solid peritoneal nodules (arrows) were present in the right hemiabdomen abutting the lateroconal fascia, the largest measuring 2 cm in size. Note multi-compartmental ascites (+).

     
    Area of Interest: Abdomen; Imaging Technique: CT; Procedure: Staging; Special Focus: Neoplasia;
     
     
  • Figure 3
    Early post-surgical unenhanced CT (3rd postoperative day)
     

    With severely impaired renal function (creatinine 5.5 mg/dl), unenhanced CT showed appearance of bilateral pleural effusions (+) and lung base atelectatic and pneumonic consolidations, and of subhepatic blood (* in b).

     
    Area of Interest: Abdomen; Imaging Technique: CT; Procedure: Complications; Special Focus: Haemorrhage;

    With severely impaired renal function, unenhanced CT showed appearance of bilateral pleural effusions (+) and lung base atelectatic consolidations, and of subhepatic blood (* in b).

     
    Area of Interest: Abdomen; Imaging Technique: CT; Procedure: Complications; Special Focus: Haemorrhage;

    The drainage tube in place (thick arrows) had its distal tip nearby the colorectal anastomosis (arrowhead), where a solitary extraluminal gas bubble (thin arrow) was seen.

     
    Area of Interest: Abdomen; Imaging Technique: CT; Procedure: Complications; Special Focus: Haemorrhage;

    The drainage tube in place (thick arrows) had its distal tip nearby the colorectal anastomosis (arrowhead), where a solitary extraluminal gas bubble (thin arrow) was seen. Note presacral effusion with 25-30 Hounsfield...

     
    Area of Interest: Abdomen; Imaging Technique: CT; Procedure: Complications; Special Focus: Haemorrhage;
     
     
  • Figure 4
    Second post-surgical unenhanced CT (7th postoperative day)
     

    With persistently impaired renal function, repeated unenhanced CT showed appearance of distended jejunal loops (§) with air-fluid levels, decreasing attenuation of subhepatic blood (* in b).

     
    Area of Interest: Abdomen; Imaging Technique: CT; Procedure: Complications; Special Focus: Obstruction / Occlusion;

    With persistently impaired renal function, repeated unenhanced CT showed appearance of distended jejunal loops (§) with air-fluid levels, decreasing attenuation of subhepatic blood (* in b).

     
    Area of Interest: Abdomen; Imaging Technique: CT; Procedure: Complications; Special Focus: Obstruction / Occlusion;

    With persistently impaired renal function, repeated unenhanced CT showed appearance of distended jejunal loops (§) with air-fluid levels, decreasing attenuation of subhepatic blood (* in b).

     
    Area of Interest: Abdomen; Imaging Technique: CT; Procedure: Complications; Special Focus: Obstruction / Occlusion;

    Pelvic images showed distended small bowel loops (§) with air-fluid levels, some blood (*) dorsal to the anastomosis (arrowhead in e), gas flowing extraluminally from a focal anastomotic discontinuity (thin arrows)....

     
    Area of Interest: Abdomen; Imaging Technique: CT; Procedure: Complications; Special Focus: Obstruction / Occlusion;

    Pelvic images viewing at bone window setting best identified gas flowing extraluminally from a focal anastomotic discontinuity (thin arrows). Note surgical colorectal anastomosis (arrowhead).

     
    Area of Interest: Abdomen; Imaging Technique: CT; Procedure: Complications; Special Focus: Obstruction / Occlusion;
     
     
  • Figure 5
    Delayed post-surgical contrast-enhanced CT (1 month after CRS)
     

    With the patient still hospitalized and improved renal function, CT showed persistence of pleural effusions (+) and atelectasis bilaterally.

     
    Area of Interest: Abdomen; Imaging Technique: CT; Procedure: Complications; Special Focus: Obstruction / Occlusion;

    Sizeable parietocolic collections (arrows) with enhancing periphery and mixed air and fluid content were present on each side of the abdomen.

     
    Area of Interest: Abdomen; Imaging Technique: CT; Procedure: Complications; Special Focus: Obstruction / Occlusion;

    Sizeable parietocolic collections (arrows) with enhancing periphery and mixed air and fluid content were present on each side of the abdomen.

     
    Area of Interest: Abdomen; Imaging Technique: CT; Procedure: Complications; Special Focus: Obstruction / Occlusion;

    Sizeable parietocolic collections (arrows) with enhancing periphery and mixed air and fluid content were present on each side of the abdomen.

     
    Area of Interest: Abdomen; Imaging Technique: CT; Procedure: Complications; Special Focus: Obstetrics;

    Sizeable parietocolic collections (arrows) with enhancing periphery and mixed air and fluid content were present on each side of the abdomen.

     
    Area of Interest: Abdomen; Imaging Technique: CT; Procedure: Complications; Special Focus: Obstruction / Occlusion;

    in the pelvis, resolution of gas flowing outside the colorectal anastomosis (arrowhead), presence of significant amount of retrorectal/presacral effusion (*).

     
    Area of Interest: Abdomen; Imaging Technique: CT; Procedure: Complications; Special Focus: Obstruction / Occlusion;

    in the pelvis, resolution of gas flowing outside the colorectal anastomosis (arrowhead), presence of significant amount of retrorectal/presacral effusion (*).

     
    Area of Interest: Abdomen; Imaging Technique: CT; Procedure: Comparative studies; Special Focus: Obstruction / Occlusion;
     
     
  • Figure 6
    Contrast-enhanced CT after rectal stenting (7 weeks after CRS)
     

    After positioning of metallic stent through colorectal anastomosis and improved renal function, CT showed resolved right lungbasal changes, persistence of left pleural effusion (+) and atelectasis.

     
    Area of Interest: Abdomen; Imaging Technique: CT; Procedure: Stents; Special Focus: Obstruction / Occlusion;

    After positioning of metallic stent through colorectal anastomosis and improved renal function, CT showed near-water attenuation effusion dorsal to the rectum, resulting from liquefaction of blood in Fig.4

     
    Area of Interest: Abdomen; Imaging Technique: CT; Procedure: Stents; Special Focus: Obstruction / Occlusion;

    Additionally, the parieto-colic collections (arrows) with enhancing periphery, mixed air and fluid content seen on each side of the abdomen showed decreasing size.

     
    Area of Interest: Abdomen; Imaging Technique: CT; Procedure: Stents; Special Focus: Obstruction / Occlusion;

    Additionally, the parieto-colic collections (arrows) with enhancing periphery, mixed air and fluid content seen on each side of the abdomen showed decreasing size.

     
    Area of Interest: Abdomen; Imaging Technique: CT; Procedure: Stents; Special Focus: Obstruction / Occlusion;

    Additionally, the parieto-colic collections (arrows) with enhancing periphery, mixed air and fluid content seen on each side of the abdomen showed decreasing size.

     
    Area of Interest: Abdomen; Imaging Technique: CT; Procedure: Stents; Special Focus: Obstruction / Occlusion;
     
     
  • Figure 7
    Distant follow-up contrast-enhanced CT (22 months after CRS)
     

    Further follow-up showed persistent absence of effusion, thickening or nodules in the peritoneum and omentum, normal aspect at the colorectal anastomosis (arrowhead in c) after removed stent.

     
    Area of Interest: Abdomen; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Neoplasia;

    Further follow-up showed persistent absence of effusion, thickening or nodules in the peritoneum and omentum, normal aspect at the colorectal anastomosis (arrowhead in c) after removed stent.

     
    Area of Interest: Abdomen; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Neoplasia;

    Further follow-up showed persistent absence of effusion, thickening or nodules in the peritoneum and omentum, normal aspect at the colorectal anastomosis (arrowhead in c) after removed stent.

     
    Area of Interest: Abdomen; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Neoplasia;

    Additionally, two small-sized (1.5 cm) hypoenhancing lesions (thin arrows) consistent with distant metastases appeared in the liver.

     
    Area of Interest: Abdomen; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Neoplasia;

    Additionally, two small-sized (1.5 cm) hypoenhancing lesions (thin arrows) consistent with distant metastases appeared in the liver.

     
    Area of Interest: Abdomen; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Neoplasia;
     
     
  • Figure 8
    CRS+HIPEC indications and exclusion criteria
     

    Indications for cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC)

     
    Area of Interest: Abdomen; Imaging Technique: CT; Procedure: Surgery; Special Focus: Neoplasia;

    Exclusion criteria from cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC)

     
    Area of Interest: Abdomen; Imaging Technique: CT; Procedure: Surgery; Special Focus: Neoplasia;
     
     
Compared to previous studies (not shown), CT showed absence of hepatosplenic lesions, a left-sided 4-cm solid mass (thick arrows) and minimal ascites (+) in the pelvis.
 
Compared to previous studies (not shown), CT showed absence of hepatosplenic lesions, a left-sided 4-cm solid mass (thick arrows) and minimal ascites (+) in the pelvis.
 
Additionally, appearance of hazy infiltration (*) of the mesocolic omental fat was noted.
 
Additionally, appearance of hazy infiltration (*) of the mesocolic omental fat was noted.
 
Repeated CT showed multi-compartmental ascites (+), increase of omental fat neoplastic infiltration (*) and of pelvic neoplastic recurrence (thick arrows), appearance of two 1.5 cm solid peritoneal nodules in epigastrium (thin arrows).
 
Repeated CT showed multi-compartmental ascites (+), increase of omental fat neoplastic infiltration (*).
 
Repeated CT showed multi-compartmental ascites (+), increase of omental fat neoplastic infiltration (*) and of pelvic neoplastic recurrence (thick arrows), the latter measuring approximately 8x4.5 cm.
 
Repeated CT showed multi-compartmental ascites (+), and of pelvic neoplastic recurrence (thick arrows), the latter measuring approximately 8x4.5 cm.
 
Repeated CT showed multi-compartmental ascites (+), increase of omental fat neoplastic infiltration (*), and appearance of two 1.5 cm solid peritoneal nodules in epigastrium (thin arrows).
 
Two additional solid peritoneal nodules (arrows) were present in the right hemiabdomen abutting the lateroconal fascia, the largest measuring 2 cm in size. Note multi-compartmental ascites (+).
 
With severely impaired renal function (creatinine 5.5 mg/dl), unenhanced CT showed appearance of bilateral pleural effusions (+) and lung base atelectatic and pneumonic consolidations, and of subhepatic blood (* in b).
 
With severely impaired renal function, unenhanced CT showed appearance of bilateral pleural effusions (+) and lung base atelectatic consolidations, and of subhepatic blood (* in b).
 
The drainage tube in place (thick arrows) had its distal tip nearby the colorectal anastomosis (arrowhead), where a solitary extraluminal gas bubble (thin arrow) was seen.
 
The drainage tube in place (thick arrows) had its distal tip nearby the colorectal anastomosis (arrowhead), where a solitary extraluminal gas bubble (thin arrow) was seen. Note presacral effusion with 25-30 Hounsfield units attenuation.
 
With persistently impaired renal function, repeated unenhanced CT showed appearance of distended jejunal loops (§) with air-fluid levels, decreasing attenuation of subhepatic blood (* in b).
 
With persistently impaired renal function, repeated unenhanced CT showed appearance of distended jejunal loops (§) with air-fluid levels, decreasing attenuation of subhepatic blood (* in b).
 
With persistently impaired renal function, repeated unenhanced CT showed appearance of distended jejunal loops (§) with air-fluid levels, decreasing attenuation of subhepatic blood (* in b).
 
Pelvic images showed distended small bowel loops (§) with air-fluid levels, some blood (*) dorsal to the anastomosis (arrowhead in e), gas flowing extraluminally from a focal anastomotic discontinuity (thin arrows). Note drainage tube (thick arrow).
 
Pelvic images viewing at bone window setting best identified gas flowing extraluminally from a focal anastomotic discontinuity (thin arrows). Note surgical colorectal anastomosis (arrowhead).
 
With the patient still hospitalized and improved renal function, CT showed persistence of pleural effusions (+) and atelectasis bilaterally.
 
Sizeable parietocolic collections (arrows) with enhancing periphery and mixed air and fluid content were present on each side of the abdomen.
 
Sizeable parietocolic collections (arrows) with enhancing periphery and mixed air and fluid content were present on each side of the abdomen.
 
Sizeable parietocolic collections (arrows) with enhancing periphery and mixed air and fluid content were present on each side of the abdomen.
 
Sizeable parietocolic collections (arrows) with enhancing periphery and mixed air and fluid content were present on each side of the abdomen.
 
in the pelvis, resolution of gas flowing outside the colorectal anastomosis (arrowhead), presence of significant amount of retrorectal/presacral effusion (*).
 
in the pelvis, resolution of gas flowing outside the colorectal anastomosis (arrowhead), presence of significant amount of retrorectal/presacral effusion (*).
 
After positioning of metallic stent through colorectal anastomosis and improved renal function, CT showed resolved right lungbasal changes, persistence of left pleural effusion (+) and atelectasis.
 
After positioning of metallic stent through colorectal anastomosis and improved renal function, CT showed near-water attenuation effusion dorsal to the rectum, resulting from liquefaction of blood in Fig.4
 
Additionally, the parieto-colic collections (arrows) with enhancing periphery, mixed air and fluid content seen on each side of the abdomen showed decreasing size.
 
Additionally, the parieto-colic collections (arrows) with enhancing periphery, mixed air and fluid content seen on each side of the abdomen showed decreasing size.
 
Additionally, the parieto-colic collections (arrows) with enhancing periphery, mixed air and fluid content seen on each side of the abdomen showed decreasing size.
 
Further follow-up showed persistent absence of effusion, thickening or nodules in the peritoneum and omentum, normal aspect at the colorectal anastomosis (arrowhead in c) after removed stent.
 
Further follow-up showed persistent absence of effusion, thickening or nodules in the peritoneum and omentum, normal aspect at the colorectal anastomosis (arrowhead in c) after removed stent.
 
Further follow-up showed persistent absence of effusion, thickening or nodules in the peritoneum and omentum, normal aspect at the colorectal anastomosis (arrowhead in c) after removed stent.
 
Additionally, two small-sized (1.5 cm) hypoenhancing lesions (thin arrows) consistent with distant metastases appeared in the liver.
 
Additionally, two small-sized (1.5 cm) hypoenhancing lesions (thin arrows) consistent with distant metastases appeared in the liver.
 
Indications for cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC)
 
Exclusion criteria from cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC)
 
 
 
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