Imaging of Peritoneal Carcinomatosis with MDCT: spectrum

of diagnostic patterns, sites involved and proposal for a new

detailed reporting scheme.

Award: Magna Cum Laude

Poster No.: C-2078
Congress: ECR 2012
Type: Educational Exhibit
Authors: M. Ciolina, P. Baldassari, M. Iannitti, A. Pichi, F. Iafrate, A. Laghi;
Rome/IT
Keywords: Pathology, Contrast agent-intravenous, CT, Education, Abdomen
DOI: 10.1594/ecr2012/C-2078

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Page 1 of 41
Learning objectives

To define Peritoneal Carcinomatosis and to briefly review its pathogenesis, the modalities
in which peritoneal metastases spread, the importance of peritoneal boundaries, of
peritoneal spaces and peritoneal fluid circulation.

To review CT appearance of peritoneal carcinomatosis underlying some typical aspects

and sites that radiologists have to check to make a detail report.

To propose a new reporting scheme.

Background

Definition:

Peritoneal Carcinosis is defined as seeding and implantation of neoplastic cells into

peritoneal cavity and may represents the advanced evolutive stage of every tumors
developed into abdominal and pelvic organs.

However ovarian, stomach and colorectal cancers accounts for almost all case 1-2.

Furthermore, there are also tumors, even though rare, that develop directly from
peritoneum (mesothelioma) or extraperitoneal organs (breast cancer).
When the disease increases, the tumoral cells reach and affect the membrane covering
the same organs (visceral peritoneum).
Once this "barrier" has been passed, the affected cells are able to move into the
abdominal cavity, carried by the peritoneal fluid.
These cells tend to accumulate in those points of greater liquid readsorption, creating
agglomerates that grow more and more, spreading into the whole abdomen and
originating the carcinosis.

Peritoneal metastases spread

When neoplastic cells reach peritoneal cavity, they continue to spread in four possible
routes 3-5:

Page 2 of 41
(1) Direct spread along peritoneal ligaments, mesenteries and omenta to non-contiguous
organs;
(2) Intraperitoneal seeding via ascitic fluid;
(3) Lymphatic extension;
(4) Embolic haematogenous spread.

Page 3 of 41
Page 4 of 41
Fig. 1
References: M. Ciolina; Department of Radiological Sciences, Oncology and
Pathology, "Sapienza" University of Rome, Rome, ITALY

Intraperitoneal seeding via ascitic fluid is one of the most important way of peritoneal
metastases spreading and the main cause of peritoneal carcinomatosis.

Peritoneal fluid circulation

The peritoneal cavity is subdivided by peritoneal reflections and mesenteric attachments

into several compartments and recesses that are anatomically continues, either directly
or indirectly 3-5.

Fig. 2: Peritoneal cavity is subdivided into several spaces and recesses by peritoneal
reflections and mesenteric insertions.
References: M. Ciolina; Department of Radiological Sciences, Oncology and
Pathology, "Sapienza" University of Rome, Rome, ITALY

Page 5 of 41
Fig. 3: Force of gravity drives pool of peritoneal fluid preferentially in pelvic cavity.
In particular, from the left infracolic space, flow is direct along the superior plane of
sigmoid mesocolon and than along the right side of the rectum. From the right infracolic
space spread occurs along the small bowel mesentery. The cul-de-sac is first filled
and then, symmetrically, the lateral paravesical recesses. From the pelvis peritoneal
fluid is able to flow upward due to the pressure gradient created by diaphragm during
inspiration and peristaltic motion of the intestine. Fluid enters the paracolic gutters and
then moves into the right subhepatic and right subphrenic regions. The left paracolic
gutter is shallow and is limited superiorly by the phrenicocolic ligament, which extends
from the splenic flexure of the colon to the diaphragm. Consequently, the majority of
fluid flows into the right paracolic gutter.

Page 6 of 41
References: M. Ciolina; Department of Radiological Sciences, Oncology and
Pathology, "Sapienza" University of Rome, Rome, ITALY

Images for this section:

Page 7 of 41
Page 8 of 41
Fig. 1

Fig. 2: Peritoneal cavity is subdivided into several spaces and recesses by peritoneal
reflections and mesenteric insertions.

Page 9 of 41
Fig. 3: Force of gravity drives pool of peritoneal fluid preferentially in pelvic cavity. In
particular, from the left infracolic space, flow is direct along the superior plane of sigmoid
mesocolon and than along the right side of the rectum. From the right infracolic space
spread occurs along the small bowel mesentery. The cul-de-sac is first filled and then,
symmetrically, the lateral paravesical recesses. From the pelvis peritoneal fluid is able
to flow upward due to the pressure gradient created by diaphragm during inspiration and
peristaltic motion of the intestine. Fluid enters the paracolic gutters and then moves into
the right subhepatic and right subphrenic regions. The left paracolic gutter is shallow
and is limited superiorly by the phrenicocolic ligament, which extends from the splenic
flexure of the colon to the diaphragm. Consequently, the majority of fluid flows into the
right paracolic gutter.

Page 10 of 41
Imaging findings OR Procedure details

CT imaging of peritoneal carcinomatosis

Peritoneal Carcinosis is characterized by the presence of neoplastic implants with

different morphological features and distribution in peritoneal cavity (6-10). Radiologist
should evaluate:

1. Morphology
2. Localization

Morphological aspects:

There are three board categories:

Solid implants
Cystic implants

Mixed implants

Page 11 of 41
Fig. 4: Different aspects of peritoneal implants. A) Axial contrast enhanced CT scan
showing solid implants (arrow) presenting as several homogenous soft tissue nodules;
B) Intraoperative image of solid implants (circle). C) Coronal contrast enhanced CT
image showing a cystic implant (arrow) over small bowel loops appearing hypodense
due to the internal fluid component. D) Intraoperative image of cystic implants
(circle). E Axial contrast enhanced CT image showing a 4 cm implant of peritoneal
carcinomatosis (arrow) presenting an ovular shape and a mixed structure consisted
of a mucinous cystic component and a solid irregular rounded wall showing contrast
enhancement. F Intraoperative image of mixed implants (circle).
References: M. Ciolina; Department of Radiological Sciences, Oncology and
Pathology, "Sapienza" University of Rome, Rome, ITALY

In all types of categories calcifications can be present or not.

Page 12 of 41
Fig. 5
References: M. Ciolina; Department of Radiological Sciences, Oncology and
Pathology, "Sapienza" University of Rome, Rome, ITALY

Solid, cystic and mixed implants can present with different patterns that depicts typical
aspects of peritoneal carcinomatosis (10).

Micronodular Pattern

Micronodular pattern is characterized by the presence of tiny 1-5 mm milky spots of

peritoneal implants diffusely involving the tunica serosa and subserosal fat. Greater
omentum, lesser omentum and mesentery are typically involved.

Page 13 of 41
Fig. 6: Micronodular Patter: a)and c) CT axial images showing several 4-5 mm
implants involving great omentum and mesentery. b) Surgical specimen of mesentery.
References: M. Ciolina; Department of Radiological Sciences, Oncology and
Pathology, "Sapienza" University of Rome, Rome, ITALY

Nodular Pattern

Nodular pattern is characterized by the presence of > 5 mm nodular implants diffusely

involving the tunica serosa and subserosal fat . Nodules may have an oval shape with
rounded contours or a star shape appearence with spiculated margins providing a stellate
pattern.

Page 14 of 41
Fig. 7: a) Axial CT image showing a stellate nodule over ascending colon.
References: M. Ciolina; Department of Radiological Sciences, Oncology and
Pathology, "Sapienza" University of Rome, Rome, ITALY

Omental cake

Omental cake consists of a diffuse nodular involvement of the greater omentum in

association with fibrotic tissue. This leadis to a consolidation of the omental fat that seems
to be stratified.

Page 15 of 41
Fig. 16: Omental Cake: a) CT axial image showing diffuse great omentum involvement
b) Surgical specimen
References: M. Ciolina; Department of Radiological Sciences, Oncology and
Pathology, "Sapienza" University of Rome, Rome, ITALY

Plaque like pattern

This aspect is typically found in subdiaphragmatic spaces and is due to the confluence
of multiple nodular implants. Plaques are irregular soft-tissue thickenings of inconstant
extension that coat abdominal viscera and peritoneal walls presenting a lower attenuation
than the parenchyma on contrast-enhanced scans.

Fig. 8: "Plaque like" implant: a) Axial contrast enhanced CT image showing a

"plaque-like" implant (arrow) over hepatic surface appearing relatively hyopdense
in comparison with surrounding parenchyma, due to the presence of a mucinous
component.b) Surgical intervention confirms the plaque like implant (arrowhead).

Page 16 of 41
References: M. Ciolina; Department of Radiological Sciences, Oncology and
Pathology, "Sapienza" University of Rome, Rome, ITALY

Mass like pattern

Mass like pattern is typically found in pelvis and comes out from the same mechanism
of 'plaque like' appearance. In this case, the confluence of multiple nodular implants can
lead to the formation of tissue mass which can reach sizes of several centimeters. When
an individual masses are about 10 cm in diameter or larger it is called "bulky tumor".

Fig. 9: "Mass like" implant: a) Axial contrast enhanced CT image showing a large
inhomogeneous soft tissue mass (arrow) located in left iliac fossa. b) Surgical
intervention confirms the bulky malignant mass.
References: M. Ciolina; Department of Radiological Sciences, Oncology and
Pathology, "Sapienza" University of Rome, Rome, ITALY

Teca aspect

Small bowel loops appear completely enveloped by a thickened layer of visceral

peritoneum that covers the bowel loops as a sleeve. Sometimes neoplastic tissue that
completely coated small bowel loops causes small bowel obstruction with consequent
dilatation of proximal loops, a condition called "ileal freezing".

Page 17 of 41
Fig. 10: Teca Aspect: a) CT coronal image b)CT axial image c) CT axial image
showing small bowel loops completely coated by a thickened visceral peritoneum.
Neoplastic tissue produces small bowel obstruction with consequent dilatation of
proximal loops, a condition called "ileal freezing". d) Surgical specimen.
References: M. Ciolina; Department of Radiological Sciences, Oncology and
Pathology, "Sapienza" University of Rome, Rome, ITALY

Neoplastic Ascitis

Ascites may be due to increased capillary permeability and fluid production or

to obstructed lymphatic vessels and decreased absorption. During inspiration fluid
accumulates in sub- diaphragmatic spaces, paracolic gutters and epiploon retrocavity. In
some cases, also in advanced stages, there is only few ascitis or it is absent.

Fig. 11
References: M. Ciolina; Department of Radiological Sciences, Oncology and
Pathology, "Sapienza" University of Rome, Rome, ITALY

Page 18 of 41
Localization of peritoneal carcinomatosis

Radiologists must specify every sites of peritoneal carcinomatosis in order to provide a

staging as detailed as possible. The best rule to make a good report is to carefully check
the surface of the bodies
covered by the peritoneal layer, peritoneal ligaments and peritoneal spaces that surround
them.
The most common sites involved by peritoneal carcinomatosis will now be considered
dividing abdomen in upper-mesocolic space, infra-mesocolic space and pelvis
and considering also retropertoneal space, subperitoneal space and subcutaneus
metastases.

Uppermesocolic space:

Fig. 12

Page 19 of 41
References: M. Ciolina; Department of Radiological Sciences, Oncology and
Pathology, "Sapienza" University of Rome, Rome, ITALY

Fig. 13
References: M. Ciolina; Department of Radiological Sciences, Oncology and
Pathology, "Sapienza" University of Rome, Rome, ITALY

Inframesocolic space:

Page 20 of 41
Fig. 14
References: M. Ciolina; Department of Radiological Sciences, Oncology and
Pathology, "Sapienza" University of Rome, Rome, ITALY

Page 21 of 41
Fig. 15
References: M. Ciolina; Department of Radiological Sciences, Oncology and
Pathology, "Sapienza" University of Rome, Rome, ITALY

Pelvis:

Page 22 of 41
Fig. 17
References: M. Ciolina; Department of Radiological Sciences, Oncology and
Pathology, "Sapienza" University of Rome, Rome, ITALY

Page 23 of 41
Fig. 18
References: M. Ciolina; Department of Radiological Sciences, Oncology and
Pathology, "Sapienza" University of Rome, Rome, ITALY

Subcutaneus tissue ("Sister Mary Joseph's Nodule") and Retroperitoneal space:

Page 24 of 41
Fig. 20: A patient with pancreatic adenocarcinoma(arrowhead) presented with multiple
cystic implants in subcutaneus tissue(white arrow), called siter Mary Joseph's nodule,
and retroperitoneal implants (blue arrow).
References: M. Ciolina; Department of Radiological Sciences, Oncology and
Pathology, "Sapienza" University of Rome, Rome, ITALY

Subperitoneal space:

Page 25 of 41
Fig. 21: Multiple cystic implants of carcinomatosis (arrow) inside mesorectum, in a
patient with rectal mucinous adenocarcinoma.
References: M. Ciolina; Department of Radiological Sciences, Oncology and
Pathology, "Sapienza" University of Rome, Rome, ITALY

Reporting Scheme

Page 26 of 41
Fig. 19
References: M. Ciolina; Department of Radiological Sciences, Oncology and
Pathology, "Sapienza" University of Rome, Rome, ITALY

Images for this section:

Page 27 of 41
Fig. 4: Different aspects of peritoneal implants. A) Axial contrast enhanced CT scan
showing solid implants (arrow) presenting as several homogenous soft tissue nodules;
B) Intraoperative image of solid implants (circle). C) Coronal contrast enhanced CT
image showing a cystic implant (arrow) over small bowel loops appearing hypodense
due to the internal fluid component. D) Intraoperative image of cystic implants (circle). E
Axial contrast enhanced CT image showing a 4 cm implant of peritoneal carcinomatosis
(arrow) presenting an ovular shape and a mixed structure consisted of a mucinous
cystic component and a solid irregular rounded wall showing contrast enhancement. F
Intraoperative image of mixed implants (circle).

Page 28 of 41
Fig. 5

Page 29 of 41
Fig. 6: Micronodular Patter: a)and c) CT axial images showing several 4-5 mm implants
involving great omentum and mesentery. b) Surgical specimen of mesentery.

Page 30 of 41
Fig. 7: a) Axial CT image showing a stellate nodule over ascending colon.

Fig. 16: Omental Cake: a) CT axial image showing diffuse great omentum involvement
b) Surgical specimen

Page 31 of 41
Fig. 8: "Plaque like" implant: a) Axial contrast enhanced CT image showing a "plaque-
like" implant (arrow) over hepatic surface appearing relatively hyopdense in comparison
with surrounding parenchyma, due to the presence of a mucinous component.b) Surgical
intervention confirms the plaque like implant (arrowhead).

Fig. 9: "Mass like" implant: a) Axial contrast enhanced CT image showing a large
inhomogeneous soft tissue mass (arrow) located in left iliac fossa. b) Surgical intervention
confirms the bulky malignant mass.

Page 32 of 41
Fig. 10: Teca Aspect: a) CT coronal image b)CT axial image c) CT axial image showing
small bowel loops completely coated by a thickened visceral peritoneum. Neoplastic
tissue produces small bowel obstruction with consequent dilatation of proximal loops, a
condition called "ileal freezing". d) Surgical specimen.

Page 33 of 41
Fig. 12

Fig. 13

Page 34 of 41
Fig. 14

Page 35 of 41
Fig. 15

Page 36 of 41
Fig. 17

Page 37 of 41
Fig. 18

Page 38 of 41
Conclusion

Pretreatment approach to Peritoneal Carcinomatosis requires an accurate staging with

detailed information about number of implants and sites involved.
Knowledge of patterns of peritoneal carcinomatosis and sites most frequently involved is
crucial for radiologists. A reporting scheme is necessary to lead report and description
of disease.

Fig. 19
References: M. Ciolina; Department of Radiological Sciences, Oncology and
Pathology, "Sapienza" University of Rome, Rome, ITALY

Page 39 of 41
Personal Information

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3. Meyers MA, Oliphant M, Berne AS, Feldberg MA. The peritoneal ligaments and
mesenteries:
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4. Meyers MA. Distribution of intra-abdominal malignant seeding: dependency on

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9. Walkey MM, Friedman AC, Sohotra P, Radecki PD. Ct manifestation of peritoneal
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