Department of RadiologyLausanne University Hospital

Switzerland

Clarisse Dromain

Imagerie de la carcinose péritonéale

Department of RadiologyLausanne University Hospital

Switzerland

Clarisse Dromain

Imagerie des métastasespéritonéales

Peritoneal tumor imaging

• High spatial resolution: small volume of implants

• High contrast resolution: – Similar attenuation to small bowel wall or

other normal tissue

– No significant enhancement

• Minimization of motion artifacts: MRI, PET-CT

A technical challenge

Peritoneal tumor imaging

– Low inter-reader variability

– Low confidence of presence: high frequency of doubtful lesions

– Too many of PM are seen only in retrospect

An interpretation challenge

• Diagnostic

• Sélection des patients pour la chirurgie

– Extension intrapéritonéale +++ • Distribution dans l’abdomen et le pelvis

– Localisations invisibles en laparoscopie

– Les atteintes nécessitant une chirurgie d’expertise

– Les atteintes associées à une faible probabilité d’obtenir une cytoréduction complète

– Les atteintes extrapéritonéales

Sugarbaker PH, De Bree E., J Surg Oncol, 2004

Rôle du radiologue

• Sensitivity – Per patient 82 à 93%– Per lesion 25 à 93%

• Depends on– Localisation of implants

• Epigastrium, subphrenic space, péri ombilical• Pelvis, mesentery, visceral peritoneum, R subphrenic

space

– Implants size– Primary tumor– Radiologist expertise *

• Warde : 3 readers, sens 30-73%

• Coakley : k = 0.35-0.50 for peritoneal thickening

k = 0.12-0.25 for small bowel involvement

*de Bree E, JSO2004; Kim SJ Radiology 2009; Warde P Am J Med Sci 1987; Coakley FV, Radiology 2002

CT: Imaging of reference

Sens. > 1cm < 0,5 cm

Jacquet 1993 79% 28%

Davies 1997 71%

De Bree 2004 > 5cm59-67%

9-24%

Koh 2009 60% 11%

Kim 2009 28,3%

Marin 2010 75% 43%

PM detection: how to improve !

• Analyze the peritoneum as an own organ: – The toblerone effect …

PM detection: how to improve !

• Use multiplanar reconstruction

• To know the different types of lesion

Peritonealthickening

Fat standingNodules

• Look at not only intraperitoneal cavity but also peritoneal fat folds – Ligaments

– Mesenteries

– Omenta

Morisson pounch

Pelvic pounch

Subprhrenic space

Spenic pounch

Round lgt

Falciform lgtLesser omentum

Coronary lgt

Triangular lgt

Mesentery

Mesocolon

PM detection: how to improve !

Améliorer la détection de la CP au TDM

• Connaitre les signes indirects de CP– Métastases ovariennes

– Dilatation urétérale

– Métastase ombilicale : nodule de sœur Mary Joseph (cancer gastrique)

– Ganglion cardiophrénique CPALN

*Koves I, et al 1993 Eur J Surg**Goéré D et al Eur J Surg Oncol. 2008;34(12):1335.

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65 ansAdénocarcinome du sigmoïde opéré il y 6 mois

Abcès tubo ovarien sur carcinose péritonéale

Carcinose

Trompe dilatée

• CPALN chain : major relay stations both for– The entire peritoneal surface– The diaphragm

• 550 patients with CRC treated by surgerywith complete peritoneal exploration

• CPALN in 245 patients (45%) on CT images

• CPALN only imaging feature associatedwith PM on multivariate analysis

• The nature (malignant or benign) of the CPALN is still unknown

CPALN

PM(n = 165) 30%

No PM(n = 385)

CPALN (%)

Yes 123 (75 %) 122 (32 %)

No 42 (25 %) 263 (68 %)

Sens Spe PPV NPV

75% 68% 50% 86%

PM for a MINEC tumor

Recurrent PM after HIPEC

May 2016After Folfiri + beva

Dec 2015

CSR + HIPEC + CPALN dissection : tumoral lymph

node involvement

Perihepatic and perisplenic ascites

CPLN

Thickenings of parietalperitoneum

Dissection of the CPLN

Signet ring cellcarcinoma

Digestive NET: Comparison MR and F-DOPA PET

PM mimickers Sigmoïd diverticulum

Spenosis implant

Mesenteric lymph nodes

Post-therapeutic fibrous nodules• Post-operative CT 2 months after surgery is helpful to dicrease FP

on CT exams

DiverticulumResidual fibrous

nodule after HIPEC

Mesenteric LN

Slenosis implant

Ganglion du mésosigmoïde

Nodule de carcinose

PM vs lymph node

• Male 51 years

• Caecal adenocarcinoma

3 months after surgery

Epiploic fat necrosis

Desmoïd tumors• Male 55 years

• Surgery for colon cancer 2 years ago

No PM:Inflammatory peritoneal

reaction

• Male 55 years

• Stenotic colon cancer

• Male 78 years, laotian origin, many trips

• Weight loss (-6Kg)

• Hemochromatosis since 1997

• Colonoscopy with colic perforation in 2008

• Laparoscopic cholecystectomy in 2014

Inflammatory granuloma : Lost intraperitoneal stones afterlaparoscopic cholecystectomy

An FDG uptake on PET CT images doesn’t mean cancer

Post-operative CTafter intra-abdominal

collection drainage

6 -months FU CT

Mme T, 64 yoPM from colon cancerCSR + HIPEC (oxaliplatine) complicated with intra-abdominal collections

• CT-PCI– Underestimation 96% of patients*

• ≥ 4 area 33,2%• small lesions, adherences **

– Overestimation less frequently : infiltration of fat

** Esquivel JSO 2010, Sala Radiology 2010

Quantitative assessment of PM distribution

• High CT-PCI is a reliable • If the CT images tumor nodules, they are almost

always present

• A low CT-PCI has a more limited prognostic• Laparoscopy ?

Meandifference

CT vs surgery (%)

PET vs surgery (%)

-2 0 7.1

-1 3.3 0

0 26.6 14.3

1 16.6 14.3

2 6.6 7.1

3 13.3 10.7

4 16.6 17.8

5 10 7.1

6 0 3.5

7 6.6 7.1

8 0 3.5

9 0 7.1

* Dromain C et al, Abdo Imaging 2008

Standardization of scoringWeb application

www.e-promise.org

www.psmss.net

Qualitative assessment of PM distribution

Radiologic features associated with high risk of incomplete surgery

• Clumped bowel

– Strong predictor of diffuse involvement of visceral peritoneum by a tumor of high grade histology

• Pluri-segmental bowel obstruction

• Involvement of the hepato-duodenal ligament

• Extensive pelvic disease, vesical trigone or 2 ureters

• Extensive peri-gastric disease

• CT-PCI > 20 (excluding PMP, cystic mesothelioma and low malignant ovarian tumors)

Sugarbaker P, C Dromain et al, Int J Hyperthermia 2017, Chamdramohan Br J Radiol 2017

Standardized reportkey imaging features that a radiology report should include

1. Description of PM

2. Distribution:□Localized □Plurifocal □Diffuse

3. Ascites– Volume: □Low □Lntermediate □High

– Type: □ Libre □ Cloisonnée □ Bloody

4. CT-PCI– Common cut-off for surgery CT-PCI < 20 (Excluding PMP and cystic

mesothelioma)

– Should take into account the primary tumor and the general status of the patient

4. High risk features for incomplete surgery:– Plurifocal bowel obstruction □No □Yes – Mesentery involvement □No □Yes – Portal hepatis infiltration and/or bile duct obstruction □No □Yes – Hydroureter □No □Yes – Psoas muscle invasion □No □Yes – Gastric outlet obstruction □No □Yes – Tumor ≥ 5cm in lesser omentum or subpyloric space □No □Yes – Tumor ≥ 5cm in jejunal regions □No □Yes – Mesenteric and retroperitoneal lymphadenopathy □No □Yes – Pleural effusion in the absence of extensive ascites □No □Yes – Pelvis sidewall invasion □No □Yes – Bladder involvement □No □Yes

5. Lesion requiring complexe surgery– Diaphragmatic involvement □No □Yes – Extensive perihepatic involvement □No □Yes – Pancreatic involvement □No □Yes – Perivascular involvement □No □Yes

6. Extraperitoneal metastases□No □Yes If yes, location:

PAUSE Criteria

• P Primary tumor and PCI

• A Ascites and abdominal wall involvement

• U Unfavorable site of involvement

• S Small bowel and mesenteric involvement

• E Extraperitoneal disease

Chandramohan a et al, Clin Radiol 2017;72:972-980

• P 16

• A 1 (ascites)

• U 1 (hep-duodenal lig.)

• S 0

• E 0

Benefits of MRI

• Increased detection of small implants – High contrast resolution with DW images

• Malignant ascites– Increased conspicuity of some tumoral implant by the suppression

of SI of ascitis fluid

• High sensitivity for some anatomic site such as subdiaphragmatic space and pelvis

• High sensitivity for mucinous PM ( PET-scan)

• Post-operative recurrent disease

• Limitation: inter-reader reproducibility < PET-CT*

*Soussan Eur radiol 2012; Satoh AJR 2011

IRM: technique

Normal CT

• Male 38 yo

• PM from sigmoïd adenocarcinoma treated by

CRS + HIPEC 10 months ago

MRI: Recurrence in the spermatic cord

T2FS PETdiffusion

Mucinous PM and retroperitoneal LN

Recurrent pseudomyxoma

Follow up of PMP

Problem solving tool in pelvis

Indication of MRI for PM detection and staging

• Current recommandation (in addition to CT)

– Staging and FU of mucinous peritoneal carcinomatosis including PMP

– Problem solving tool ( pelvis ++)

– Increased markers with normal CT (vs PET-CT)

• Option

– Pré-operative staging of peritoneal metasases

DW-MRI Limites• T2 Shine –Through : hypersignal persistant des structures à fort T2

(composante liquidienne): faux positifs– Images d’ADC

– Comparaison aux images morphologiques

• Tumeurs à faible densité cellulaire– T séreuses et mucineuses : aspect hétérogène, valeur élevée de l’ADC

– T calcifiées (ovaire) hyposignal T2 et T2 diffusion.

DWI b= 0 DWI b= 0

ADC

Take home message

• Accurate interpretation with knowledge of direct and indirect signs may significantly improved the per-site detection of PM

• Standardization of CT reports with description of high risk lesions is crucial for selection of patient suitable HIPEC and cytoreduction surgery or PIPAC– Will also facilitate multicenter clinical trials– Will facilitate to follow longitudinal studies of response to

therapy

• MRI is useful in staging and FU of mucinousperitoneal carcinomatosis including PMP and problem solving

Thank you for your attention Clarisse.Dromain@chuv.ch