imaging of peritoneal carcinomatosis

1. Imaging
of
peritoneal
carcinomatosis
C.HOEFFEL,
Reims
P.ROUSSET,
Lyon
HANOI,
NOV
2015

2. ObjecHves
• Understand
why
evaluaHon
of
carcinomatosis
is
necessary
• Understand
where
to
look
for
and
how
to
quanHfy
carcinomatosis
• Know
the
protocol
of
CT
and
MR
examinaHons
for
evaluaHon
of
carcinomatosis
• Know
the
role
and
added
value
of
involved
imaging
modaliHes
in
evaluaHon
of
carcinomatosis

3. General
consideraHons
• Primary
– GI
:
colo-­‐rectal,
pancreaHc,
gastric
– Ovary/Breast
• Outcome
– Median
survival:
7
months,
OS-­‐2
years
:
15%
– Limited
penetraHon
of
systemic
chemotherapy

4. • New
agressive
treatment=
standard
[
for
paHents
with
disease
confined
to
peritoneum
and
CRC
– Removal
of
macroscopical
– HIPEC:
high
local
concentraHon
of
chemotherapy,
increased
in
drug
toxicity
with
heat,
for
microscopical
– OS-­‐3
years:
53
%
and
OS-­‐5
years:
48.5
%
– 30
%
morbidity,
4
%
mortality
General
consideraHons

5. ROLE
OF
IMAGING
• Not
only
Diagnosis
but
• Extension
for
strategy
–
selecHon
of
paHents
for
surgery
+++,
even
if
perop
evaluaHon=
ref
– PCI
=
peritoneal
cancer
index=>
score
0
to
39
(12
regions),
ex
Sugarbaker
score
• Diameter
:
score
1
=
0-­‐5
mm,
score
2=
5
mm-­‐5
cm,
score
3
>
5
cm
– Probability
to
obtain
R0
surgery
and
taken
into
account
as
CI
to
surgery
when
too
high
for
a
type
of
cancer
Sugarbaker PH, De Bree E., Jour Surg Oncol, 2004

6. • Extension
necessitaHng
expert
centre:
– ResecHon
of
diaphragm
for
diaphragmaHc
nodule
– HepaHc
parenchymal
invasion
from
implants,
Bowel
implants
– Bladder
or
ureteral
invasion
• Idea
of
length
and
morbidity
• No
current
consensus
on
criteria
for
subopHmal
resecHon
but
some
lesions
suggest
non
resectability
ROLE
OF
IMAGING
Low AJR 2008 Low. Ann Surg Oncolo.2013 Nougaret.
Radiographics
2013

7.
Alert
surgeons
to
to
the
presence
of
disease
that
may
complicate
surgery
or
may
preclude
opHmal
debulking
.
Extensive
involvement
of
small
bowel-­‐
diffuse
mesenteric
infiltraHon
or
retracHon
of
the
root
of
mesentery

9. • Bulky
hepatoduodenal-­‐
involved
node
sup
to
celiac
axis
• Involvement
of
vesical
trigone
-­‐
pelvic
sidewall
Non
mucinous
CRC-­‐
not
resectable
because
involvement
of
duodenal
extension

10. • IdenHfy
extraperitoneal
lesions
– Liver
small
or
central
mets
in
liver
,
spleen
not
seen
with
lap
– Lymph
nodes
– Abdominal
wall
– Pleura
– Bone
Role
of
Imaging

11.
– Liver
– Lymph
nodes
– Abdominal
wall
– Pleura-­‐
inaccessible
with
lap
– Bone

12.
– Liver
– Lymph
nodes
– Abdominal
wall
– Pleura-­‐
inaccessible
with
lap
– Bone

13. Where
to
look
for
carcinosis?
– Gravity
dependent
areas
or
of
arrested
flows
• Pelvic
recesses
(rectouterine,
lateral
paravesical,
RLQ),
Right
paracolic
gu[er
(phrenicocolic
lig
upward
on
the
lel),
ACE,
Morisson’s
recess,
Right
subdiaphragmaHc
space
• RS
J,
Ileocaecal
juncHon,
pylorus
– Peritoneal
folds
containing
fat
• Ligaments
:
reflexion
area
between
visceral
and
parietal
p
• Mesos
:
mesentery,
transverse
meso
colon,
mesosigmoïd
• Omentum
Nougaret
et
al.
RadioGraphics
2012.
32,
No.
6:
1775-­‐1800

14. PCI
SCORE-­‐Features
•
Involvement
of
parietal
serosa
:
peritoneal
thickening-­‐
nodules
•
Involvement
of
fa[y
areas
(omental
cake)
Nougaret
et
al.
RadioGraphics
2012
Vol.
32,
No.
6:
1775-­‐1800
plaques
infiltration
Reticulonodular lesions
Mass (confluent nodules)

15. •
Involvement
of
visceral
serosa
– Extrinsic
tumoral
infiltraHon
(ileocaecal,
right
colonic
angle,
RSJ)
– Distorsion
SB
(retracHon
of
mesentery)-­‐
Thickening
– ObstrucHon

16. PCI SCORE-Features
Pr Valette PJ. Lyon

17.
Adhesions=
deviaHon
of
a
structure
to
another
or
thickening
between
two
structures
without
fat
interface.

18.
nodules
of
the
mesentery
if
>7mm,
and/if
irregular
hypodense
nodules
and/if
numerous
:
grouped
and
>
8
on
one
slice

19. Other
signs
• Ureteral
dilataHon
without
any
obstacle
• Cardiophrenic
lymph
node
– 550
pts
with
CRC
– 30
%
proven
PC
– VPN
85
%/VPP
49
%
Caramella.
Eur
J
Cancer
2013
Two years after surgery for CRC.
Ureteral dilatation due to carcinomatosis

20. Pseudomyxoma
• Intraperitoneal
seeding
of
mucin
secreHng
cells
responsible
for
mucin
in
the
peritoneum
– Low
grade
and
high
grade
according
to
OMS
2010
– From
mucinous
appendicular,
ovary
• Features:
– Diffuse
involvement
– Thick
asciHs
with
scalloping
or
septas
– Possibility
of
calcificaHons
– Rarely
nodules
and
masses,
associated
organ
involvement
or
extent
to
pleura

21. ROLE
of
CT
• Reference
imaging
for
staging
and
restaging
of
paHents:
>90
%
/paHent
• Easily
available,
quick,
large
FOV
– SpaHal
resoluHon
(1
mm
thick
slices)
and
3D
reformats:
reconstrucHon
using
3
mm
slices-­‐
– Anayze
coronal
reformats
:
Nodule
in
at
least
two
planes
increases
confidence
in
diagnosis
• Protocol:
IV
+±1
l
water
IV-­‐
for
ovary
and
CRC
(30
%
with
calcificaHons)
Chandrashekhara.
BJR.2011
Mazzei
2013.
Abdominal
imaging

22.
• PCI:
underscores
staging
compared
with
surgery
• Depends
on
size
– Se
<
15%
for
T<
0.5
cm
(miliary
in
liniHs)
– Se
<
25%
for
T
<
1
cm
– Se
around
40%
for
T
=
0.5
-­‐
5
cm
– Se
60
to
94%
for
T
>
5
cm
De
Bree.
JSO
2004
Koh
Ann.
Surg
Oncol
.2009
Esquivel.
JSO
2010
Sala.
Radiology.
2010
ROLE
OF
CT-­‐
Limits
small lesion on mesentery
plaque like lesion

23. ROLE
OF
CT-­‐
Limits
• Depends
on
site
–
Se<
20%
for
small
bowel
and
mesentery
– Se
poor
for
diaphragmaHc
lesions
– Se
variable
for
pelvis
• Depends
on
level
of
experience
• Depends
on
type
of
lesion
:
nodule
(k=0.8)/
thickening
(k=0.4)/distorsion
(k=0.2)
• Depends
on
amount
of
fat
De
Bree.
JSO.
2004

24. ROLE
OF
CT-­‐
Limits
•
CharacterizaHon
of
nodules
and
of
asciHs

25. Role
of
CT-­‐Limits
Limits=
specificity

26. ROLE
OF
MRI
• Few
studies
available,
parHcularly
in
paHents
without
neoadjuvant
treatment
• MRI
versus
CT
– Qayyum.
Gynecol
oncol
2005:
137
pts,
CT
=
MRI
– Torkzad.
JSO
2015:
39
pts,
PCI
radio
CT
=
MRI,
EXCEPT
junior
– Low.
Ann
surg
oncol.
2015:
22
pts:
Acc
=
85
vs
63%
• MRI
versus
PET
– Soussan.
Eur
radiol
2012:
30
pts
(13/33
(43%
opérés)
Ac
=
83
vs
80%
per
p[
per
site
MRI
+
per
lesion
– Klumpp.
abdo
imaging
2012:
15
pts:
88
vs
94%.
MRI
without
diffusion
• MRI
alone
–
pseudomyxoma
– Low.
Ann
Surg
Oncol
2012:
33
p[s
(25
PMP)
Acc
0.84

27. MR
PROTOCOL
• Fast/PEG
500
cc?
• AnHperistalHc
agents
before
gadolinium
injecHon
=
glucagon
• MRI
of
abdomen
and
pelvis
-­‐
2
stacks
to
cover
the
whole
peritoneal
cavity
– Axial
T2
single
shot
FSE
(trigger
free
breathing,
not
as
good
with
echo
nav),
5-­‐6
mm,
sans
Fatsat
– Axial
Diffusion
(b
0-­‐800)
– Axial
post
gadolinium-­‐enhanced
T1-­‐weighted
art/
portal/late
phase
(5
minutes).

28. T2
:
Added
value
for
PCI
assessment
•
limited
added
value
in
non
mucinous
lesions

29. T2
:
Added
value
for
PCI
assessment
•
added
value
++
for
mucinous
lesions

30. Gadolinium:
Added
value
for
PCI
assessment
• non
mucinous
lesions-­‐
peritoneal
thickening

31. Gadolinium: Added value for PCI
assessment

32.
Gadolinium:
Added
value
for
PCI
assessment
Mucinous lesions

33. Tissu sain Tissu tumoral
Diffusion:
Added
value
for
PCI
assessment-­‐Contrast
resoluHon-­‐
detecHon

34. Diffusion:
Added
value
for
PCI
assessment-­‐DetecHon
Diffusion:
non
mucinous
lesions-­‐
added
value
parHcularly
for
difficult
areas
with
CT
Low
-­‐
AJR
2009
:
255
sites
lésionnels
n Standard
MRI
se
73
-­‐
52%,
sp
92%
(k
=
0,67)
n Diffusion
b
=
500
se
71
-­‐
71%,
sp
90%
(k
=
0,67)
n MR
conv.
+
Diff
se
90
-­‐
84%,
sp
91%
(k
=
0,77)

37. Small
bowel
serosa
<
5
mm
Added
value
for
pelvis
and
small
bowel
WARN
SURGEON
=>
morbidity

38.
Abdominal
wall
lesion
<
10
mm
Added
value
for
special
sites
such
as
abdominal
wall

39. Diffusion:
Added
value
for
PCI
assessment-­‐CharacterizaHon

40. Diffusion-­‐Limits
• Limits
of
diffusion
sequences
– T2
shine
through
effect=>
ADC
– RestricHon
of
diffusion
from
less
cellular
some
lesion:
mucin,
adhesions,
confluent
areas,
fibrosis
– Lesions
with
blood,
mucoid
content

41. MR
Technique-­‐Limits
• PaHent-­‐dependent
• PeristalHsm
• Black
hole
effect-­‐
get
rid
of
the
asciHs
before
MRI
• ParHal
volume
effect-­‐spaHal
resoluHon
• Interobserver
Variability
(per
site)-­‐
learning
curve

42. PET
CT-­‐
Main
IndicaHons
• Strong
Clinical
suspicion
of
PC
or
increase
in
markers
level
with
normal
CT
• DetecHon
of
recurrence
versus
fibrosis
• Assessment
before
HIPEC
– Underscores
PCI
but
complementary
to
CT/MRI
– Rules
out
extraperitoneal
lesions
contraindicaHng
surgery

43. – False
negaHve
• Mucinous
tumors,
low
grade
pseudomyxoma
and
gastric
liniHs
PET
CT-­‐
Limits
Passot.Eur
J
Surg
Oncol.
2010
Anthony.
AJR.2009
Hymnimen.
Gynecol
oncol.
2013

44. PET
CT-­‐
Limits
• False
negaHve
– Size
<
1cm
– Hidden
lesions
by
respiratory
and
GI
movements
• False
posiHve:
specificity
<
CT
– Inflammatory
reacHon
of
peritoneum
around
large
or
numerous
implants
– Foreign
body
or
inflammatory
reacHon
related
to
previous
surgery
– Physiological
uptake
of
bowel
and
vessels
Pierandrea
de
Iaco.
EJR.
2011

45. Conclusion
– CT=
reference
imaging
– Before
deciding
upon
treatment
MRI
±PET
scanner
needed
• For
assessment
of
PCI
• Detect
lesions
needing
expert
center
• Detect
non
resectable
disease
– Added
value
of
diffusion
for
small
bowel,
pelvis
,
hepaHc
hilum,
pseudomyxoma
++
– PET/CT
for
extraperitoneal
disease
– COMBINE
modaliHes

46. Peritoneal
Thickening