CASE 14308 Published on 06.01.2017

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

Section

Abdominal imaging

Case Type

Clinical Cases

Authors

Tonolini Massimo, M.D.

"Luigi Sacco" University Hospital,Radiology Department; Via G.B. Grassi 74 20157 Milan, Italy; Email:mtonolini@sirm.org

Patient

75 years, female

Categories

Area of Interest Abdomen ; Imaging Technique CT

Procedure Surgery, Complications, Staging, Diagnostic procedure, Stents, Comparative studies ; Special Focus Neoplasia, Obstruction / Occlusion, Haemorrhage, Obstetrics ;

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Clinical History

A woman presented having had radical surgery for ovarian carcinoma two years earlier, and currently on periodic oncologic surveillance. The medical history also includes hip arthroplasty, hypertension and hypothyroidism. Normal laboratory tests including serum CA-125 marker.

Imaging Findings

Initial CT (Fig.1) showed the appearance of omental infiltration, minimal peritoneal fluid and a left-sided mass in the pelvis suggesting neoplastic recurrence. Despite systemic chemotherapy, repeated CT (Fig.2) showed progressive intra-abdominal neoplastic disease including ascites, increased pelvic mass, additional peritoneal nodules and worsened omental infiltration, quantified as 9 according to peritoneal carcinomatosis index.
Total peritonectomy was performed including en-bloc resection of rectosigmoid colon, uterus and adnexa, splenectomy, left hemicolectomy, and was followed by hyperthermic intraperitoneal chemotherapy with cisplatin+doxorubicin. The early postoperative course was complicated by acute renal failure, blood loss, pneumonia (Fig.3), bowel obstruction and anastomotic dehiscence (Fig.4).
A month after surgery, CT (Fig.5) showed presacral fluid and bilateral parietocolic collections with enhancing periphery, which required stenting (Fig.6) through the ulcerated colorectal anastomosis to relieve sepsis. Afterwards the patient improved and was discharged.
Further CT follow-up showed persistent absence of peritoneal carcinomatosis and ultimate development of small-sized liver metastases (Fig.7).

Discussion

Until a decade ago, peritoneal carcinomatosis (PC) meant advanced neoplastic disease and its natural history indicated a dismal (median survival 6 months) prognosis, therefore treatment was palliative or supportive. Since Sugarbaker considered PC a regional (not metastatic) process, the current multimodal treatment consisting in aggressive cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) has become the best treatment option, which improves the oncological outcome and is potentially curative in selected patients. Overall 3-year survival rates are 31-41%. Following removal of all visible tumour, intraoperative chemotherapy is administered in the peritoneal cavity with hyperthermia (40°-42°C) to eradicate residual microscopic disease by reaching high drug concentrations with enhanced efficacy and reduced systemic side effects. Complete (no visible seeding) or near-complete (residual tumour <2.5 mm) cytoreduction after CRS is the major prognostic factor [1-5].
However, CRS-HIPEC is a technically challenging procedure which requires correct patient selection and high surgical skill. Indications and exclusion criteria are listed in Figure 8. The peritoneal cancer index (PCI) quantifies the tumour burden for operability and prognosis by dividing the abdomen in 9 sectors plus four small bowel segments, each assigned a score of 0 (no tumour), 1 (≤5 mm), 2 (≤5 cm) or 3 (>5 cm). PCI estimates the likelihood of complete cytoreduction albeit CT-based PCI underestimates intraoperative findings in 33% of patients, particularly with small (<5 mm) nodules. PCI ≤10 predicts a reasonably favourable outcome (40% 5-year survival) [3, 5, 6].
CRS requires complete greater omentectomy, splenectomy, left and right upper quadrant peritonectomy, dissection and tumour removal below hemidiaphragm, from right subhepatic space and liver surface, lesser omentectomy and cholecystectomy, omental bursa stripping, pelvic peritonectomy, rectosigmoid colon resection, transection of rectum beneath the peritoneal reflection, hysterectomy, vaginal closure and colorectal anastomosis, plus antrectomy and gastric reconstruction or complete gastrectomy. CRS is associated with frequent (21-44%) major complications and non-negligible (0.7-8%) mortality. Morbidity is strongly influenced by high tumour burden requiring extensive dissection, multiple visceral resection and bowel anastomoses. In descending order of frequency, main complications include sepsis (28-35%), blood loss (22%), respiratory distress and pleuropulmonary problems, intestinal obstruction, enteric fistulas, pancreatitis, renal failure and bile leakage. As this case exemplifies, CT is invaluable in patient selection with regard to PCI and anatomic exclusion criteria, for elucidation of postsurgical complications, and for long-term follow-up during which up to two-thirds of patients ultimately develop recurrence [3, 5, 7-12].

Differential Diagnosis List

Peritoneal carcinomatosis from ovarian cancer. Cytoreductive surgery + hyperthermic intraperitoneal chemotherapy.

Ascites from decompensated cirrhosis

Abdominal tuberculosis

Disseminated gastric or colonic cancer

Recurrent peritoneal carcinomatosis

Final Diagnosis

Peritoneal carcinomatosis from ovarian cancer. Cytoreductive surgery + hyperthermic intraperitoneal chemotherapy.

References

[1] Lungoci C, Mironiuc AI, Muntean V, et al (2016) Multimodality treatment strategies have changed prognosis of peritoneal metastases. World J Gastrointest Oncol 8:67-82. (PMID: 26798438)

[2] Munoz-Casares FC, Medina-Fernandez FJ, Arjona-Sanchez A, et al (2016) Peritonectomy procedures and HIPEC in the treatment of peritoneal carcinomatosis from ovarian cancer: Long-term outcomes and perspectives from a high-volume center. Eur J Surg Oncol 42:224-233 (PMID: 26673283)

[3] Terzi C, Arslan NC, Canda AE (2014) Peritoneal carcinomatosis of gastrointestinal tumors: where are we now?. World J Gastroenterol 20:14371-14380 (PMID: 25339824)

[4] Sugarbaker PH (2005) Surgical management of carcinomatosis from colorectal cancer. Clin Colon Rectal Surg 18:190-203. (PMID: 20011302)

[5] Yonemura Y, Canbay E, Ishibashi H (2013) Prognostic factors of peritoneal metastases from colorectal cancer following cytoreductive surgery and perioperative chemotherapy. ScientificWorldJournal :978394 (PMID: 23710154)

[6] Koh JL, Yan TD, Glenn D, et al (2009) Evaluation of preoperative computed tomography in estimating peritoneal cancer index in colorectal peritoneal carcinomatosis. Ann Surg Oncol 16:327-333 (PMID: 19050972)

[7] Baratti D, Kusamura S, Iusco D, et al (2014) Postoperative complications after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy affect long-term outcome of patients with peritoneal metastases from colorectal cancer: a two-center study of 101 patients. Dis Colon Rectum 57:858-868. (PMID: 24901687)

[8] Massari R, Barone M, Basilico R, et al (2014) Peritonectomy and hyperthermic chemotherapy in patients with advanced or recurrent ephitelial ovarian cancer: a single center cohort study. Minerva Chir 69:17-26 (PMID: 24675243)

[9] Valle M, Federici O, Carboni F, et al (2014) Postoperative infections after cytoreductive surgery and HIPEC for peritoneal carcinomatosis: proposal and results from a prospective protocol study of prevention, surveillance and treatment. Eur J Surg Oncol 40:950-956 (PMID: 24246609)

[10] Saxena A, Yan TD, Morris DL (2010) Critical assessment of preoperative and operative risk factors for complications after iterative peritonectomy procedures. Eur J Surg Oncol 36:309-314 (PMID: 19615849)

[11] Di Giorgio A, Naticchioni E, Biacchi D, et al (2008) ytoreductive surgery (peritonectomy procedures) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) in the treatment of diffuse peritoneal carcinomatosis from ovarian cancer. Cancer 113:315-325 (PMID: 18473354)

[12] Malfroy S, Wallet F, Maucort-Boulch D, et al (2016) Complications after cytoreductive surgery with hyperthermic intraperitoneal chemotherapy for treatment of peritoneal carcinomatosis: Risk factors for ICU admission and morbidity prognostic score. Surg Oncol 25:6-15 (PMID: 26979635)

Case information

URL:	https://www.eurorad.org/case/14308
DOI:	10.1594/EURORAD/CASE.14308
ISSN:	1563-4086

License

This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.

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.

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

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 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 (+).

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).

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.

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).

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).

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.

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 (*).

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.

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.

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.