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Case presentation

Case presentation. 新光醫院 核子醫學科 葉力豪 2010/3/13. Case 1: History. 70 y/o female PH: HBV & HCV carrier DM CC: Lower abdominal pain for one month Dull and intermittent No aggravating or relieving factors. Case 1: History. Gynecology sonography (2008/9/24):

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Case presentation

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  1. Case presentation 新光醫院 核子醫學科 葉力豪 2010/3/13

  2. Case 1: History • 70 y/o female • PH: • HBV & HCV carrier • DM • CC: Lower abdominal pain for one month • Dull and intermittent • No aggravating or relieving factors

  3. Case 1: History • Gynecology sonography (2008/9/24): • WNL, Bil. Adnexa: invisible • Colonoscopy (2008/9/26): • internal hemorrhoid • U/A: normal • CT of abdomen and pelvis (2009/10/29):

  4. Peritoneal carcinomatosis Omental thickening (Omental cake) nodularity

  5. Omental thickening (Omental cake) nodularity

  6. Case 1: History • Tumor marker (2008/10/31): • CEA: 0.7 (0~5) • CA125: 93.91 (0~35) • CA19-9: 7.27 (0~27) • Gynecology sonography (2008/11/5): • Bilateral adnexa: invisible

  7. FDG-PET/CT (2008/11/6)

  8. Omental thickening

  9. Omental thickening

  10. Omental thickening

  11. Case 1: History • Impression: Primary peritoneal carcinoma • Laparotomy (2008/11/13): • Large omental cake adhesion to anterior peritoneal layer • Someascites< 50 cc • Nodularity over whole peritoneum, esp. cul-de-sac, bilateral pelvic cavity and anterior bladder wall • Bilateral adnexa: grossly normal, about 2x1cm(Rt) & 1.5x1cm(Lt)

  12. Case 1: History • Operative procedures: • Bil. salpingo-oophorectomy + omentectomy + retroperitoneal tumor biopsy + washing cytology • Pathology: • Left ovary: Serous cystadenocarcinoma • Right ovary: Negative for malignancy • Omentum metastases(>2cm, T3c, Stage IIIC)

  13. Case 2: History • 49 y/o female • Past History: • Asthma • Hyperthyroidism • Major depression • G4P2, Perimenopause • Appendicitis s/p appendectomy • Bilateral ovarian chocolate cysts s/p operation

  14. Case 2: History • Chief Complaint (2008/12): • Lower abdominal pain • CA-125: 92.3 (normal < 35)

  15. Case 2: History • Gyn echo (2008/12/26) : • Uterine myoma • R’t ovary: 2.46 x 1.59 cm • Suspicious left ovarian cyst: 2.68 x 1.66cm

  16. Case 2: History • 2009/4/29: • CA-125: 93.71 U/ml (normal < 35) • CA-153: 64.08 U/ml (normal < 30) • Breast echo: normal • Gyn echo: • R’t ovary : 1.94 x 1.46 cm • L’t ovary : unremarkable • Adenomyosis of uterus

  17. 2009/6/23

  18. Omental thickening Omental thickening

  19. Omental thickening Cul-de-sac

  20. Cul-de-sac Omental thickening

  21. Omental thickening

  22. Case 2: History • Operation at 和信醫院: • Total abdominal hysterectomy + bilateral salpingo-oophorectomy + pelvic LN dissection + Cul-de-sac & peritoneal tumor resection + omentectomy

  23. Case 2: History • Patholgy: • Bil. Ovary & fallopian tube: • High grade papillary serous carcinoma • R’t ovary: 2.5 x 2 x 1.5 cm • L’t ovary : 2.5 x 1.1 x 0.5 cm

  24. Case 2: History • Cul-de-sac, peritoneum, omentum: • High grade papillary serous carcinoma • Serosal surface of the uterus, pelvic LNs: • metastatic adenocarcinoma(N1 stage  Stage IIIC at least) • Uterus: • four myoma (measuring up to 3.4 cm)

  25. Discussion

  26. Peritoneal Carcinomatosis • Definition: Extensive, or very widespread, metastasis of cancerous tumors onto the inside surfaces (peritoneum) of the abdomen.

  27. Peritoneal Carcinomatosis • Occurs commonly with abdominopelvic tumors • Most common tumors: • Ovarian carcinoma (female) • Gastric cancer • Pancreas cancer • Colon cancer

  28. Peritoneal Carcinomatosis • Ascites • Soft tissue masses or thickening of the parietal peritoneum • Omental thickening (omental cake) • Tumor nodules & enlarged LNs in the mesentery • Thickening & nodularity of the bowel wall

  29. Anatomy of peritoneum From: http://www.bala6y.org/vb/showthread.php?t=11687

  30. Pathways of ascites & sites of tumor seeding Abdom Imaging (2009) 34: 391-402

  31. Bil. Ovarian cancer with peritoneal seeding

  32. Peritoneal seeding to paracolic gutters & greater omentum Omental thickening Paracolic gutter Omental thickening Paracolic gutter

  33. Peritoneal seeding to Morison’s pouch Morison’s pouch

  34. Peritoneal seeding to falciform ligment

  35. Peritoneal seeding to subdiaphragmatic surface

  36. Rectal cancer with abdominal wall and bowel loop involvement

  37. Mesenteric neoplatic implants with bowel loop involvement Abdom Imaging (2009) 34: 391-402

  38. Mesenteric neoplastic nodule Abdom Imaging (2009) 34: 391-402

  39. Perirectal ovarian carcinoma neoplastic implants Abdom Imaging (2009) 34: 391-402

  40. Ovarian carcinoma-cystic peritoneal neoplastic implant Abdom Imaging (2009) 34: 391-402

  41. Neoplastic nodule in the adipose tissue of the hernia sac Abdom Imaging (2009) 34: 391-402

  42. FDG-PET/CT in peritoneal carcinomatosis • False negative: • Cystic lesions • Small volume disease or miliaric seeding • False postive: • Bowel activity • Focal retained activity in ureters and urinary bladder Abdom Imaging (2009) 34: 391-402

  43. Peritoneal Carcinomatosis • D.D.: • Lymphoma • Primary peritoneal mesothelioma • Gastrointestinal stromal tumors • Peritoneal tuberculosis Indian J Radiol Imaging 2010;20:58-62

  44. Normal-sized ovarian carcinoma syndrome • Diffuse metastatic disease of the peritoneal cavity. • Ovaries are macroscopically normal(<4cm) or only have fine nodularities on the external surface. Obstet Gynecol. 1989;73(5 Pt 1):786-92.

  45. Normal-sized ovarian carcinoma syndrome • Including: • Mesothelioma • Primary peritoneal carcinoma • Primary ovarian carcinoma ( Serous surface papillary carcinoma of ovary, Papillary serous carcinoma in ovaries of normal size) • Metastatic tumor from another primary origin Obstet Gynecol. 1989;73(5 Pt 1):786-92.

  46. Serous surface papillary carcinoma of ovary • Originating from the surface epithelium of the ovary • Absence of involvement or only microscopic involvement of the ovarian parenchyma. • A distinct subtype of serous papillary carcinoma of the ovary • Extensive peritoneal spread Acta Radiologica 38 (1997) 847-849

  47. Serous surface papillary carcinoma of ovary • Imaging findings (CT, US, MRI): • Diffuse nodularities along the serosal surface of the ovaries, uterus and peritoneum without ovarian mass. • The nodular lesions obliterated the outer margin of uterus and ovaries. Acta Radiologica 38 (1997) 847-849

  48. Omental thickening (Omental cake) nodularity

  49. Serous surface papillary carcinoma of ovary • Elevated CA-125 in all pts (most > 200 U/ml) AJR 2004;183:1721–1724

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