CASE 14308 Published on 06.01.2017

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


Abdominal imaging

Case Type

Clinical Cases


Tonolini Massimo, M.D.

"Luigi Sacco" University Hospital,Radiology Department; Via G.B. Grassi 74 20157 Milan, Italy;

75 years, female

Area of Interest Abdomen ; Imaging Technique CT
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).
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.
Case information
DOI: 10.1594/EURORAD/CASE.14308
ISSN: 1563-4086