eMedicine Specialties > Oncology > Carcinomas of the Gastrointestinal Tract

Peritoneal Cancer: Differential Diagnoses & Workup

Author: Wissam Bleibel, MD, Staff Physician, Department of Internal Medicine, Caritas Carney Hospital, Tufts University School of Medicine
Coauthor(s): Olga Kozyreva, MD, Fellow, Department of Hematology-Oncology, Tufts University School of Medicine; Sarah K May, MD, Consulting Staff, Department of Hematology-Oncology, Caritas Carney Hospital, Commonwealth Hematology-Oncology PC; Daniel Efiom-Ekaha, MD, Fellow in Hematology/Oncology, Department of Internal Medicine, State University of New York-Downstate; Arunbhai G Patel, MD, Chief, Department of Internal Medicine, Division of Hematology-Oncology, Brooklyn Hospital Center; Adekunle Kuku, MD, Staff Physician, Department of Internal Medicine, Brooklyn Hospital Center
Contributor Information and Disclosures

Updated: Jul 23, 2007

Differential Diagnoses

Ovarian Cysts

Other Problems to Be Considered

The differential diagnosis of primary peritoneal cancers includes peritoneal metastasis (ie, peritoneal carcinomatosis) from primary sites including the GI tract, ovaries, or breast or as part of the syndrome of adenocarcinomas of unknown primary site. Although the primary histology findings dictate the clinical course, important concepts of diagnosis and treatment are common to all forms. The most important risk factor for developing peritoneal carcinomatosis is the depth of invasion of the primary tumor.

Reactive tumorlike lesions of the peritoneum have been described and should be included in the differential diagnosis of primary peritoneal cancers, as follows:

  • Granulomatous lesions
    • Vernix caseosa and meconium peritonitis
    • Granulomatous peritonitis secondary to foreign material, including keratin
    • Necrotic pseudoxanthomatous nodules
    • Postcautery granulomas
  • Nongranulomatous histiocytic lesions
    • Ceroid-rich histiocytic infiltrates
    • Peritoneal melanosis
    • Mucicarminophilic histiocytosis
    • Other histiocytic infiltrates
  • Fibrosing lesions
    • Sclerosing peritonitis
    • Peritoneal fibrosis nodules
  • Mesothelial lesions
    • Mesothelial hyperplasia
    • Peritoneal inclusion cysts
Pseudomyxoma peritonei typically includes any low-grade or benign tumor within the abdominal cavity that produces copious amounts of mucinous ascites. This condition includes peritoneal spread from well-differentiated adenocarcinomas of the GI tract and benign mucin-secreting adenomas of the appendix.

Workup

Laboratory Studies

Malignant peritoneal mesothelioma: Findings from cytologic examination of ascites can suggest the diagnosis, and findings from percutaneous biopsy of the omentum can help verify the diagnosis. This condition is usually confined to the abdomen at the time of diagnosis.

Imaging Studies

  • Standard imaging tests, including ultrasonography and helical CT scans, are notably insensitive for the detection of peritoneal tumors.
    • The sensitivity of CT scans for peritoneal nodules measuring smaller than 1 cm is approximately 15-30%.
    • Ultrasonography is similarly insensitive; therefore, considering findings, rather than solid tumor detection, that may suggest the presence of peritoneal lesions is important. These include the presence of ascites, fixing together of bowel loops, thickening of mesentery, and omental matting.
  • CT scan findings are nonspecific in primary papillary serous carcinoma of the peritoneum. Consider this diagnosis when findings include ascites, omental caking, and diffuse enhancement with nodular thickening of the parietal peritoneum of the pelvis observed with normal-sized ovaries, with or without a fine enhancing surface nodularity of the ovary.
  • Some studies show that MRI is superior to helical CT scan for the detection of peritoneal and bowel wall abnormalities.
  • Positron emission tomography imaging has not been shown to be sensitive for lesions smaller than 1 cm in the abdominal cavity.
  • Findings from radionuclide scan studies can help confirm the diagnosis of peritoneal hemangiomas; the isotope concentrates in the area where platelets are being sequestered. A CT scan and ultrasound also may detect larger hemangiomas. Angiographic evaluation is a more precise, although invasive, procedure when radionuclide scans, CT scan, and ultrasound findings are negative.

Procedures

  • Procedures for the workup of peritoneal lesions include peritoneal lavage cytology. This can be performed using a cutaneous closed technique or at the time of laparoscopy or laparotomy. The sensitivity of the test results depends on the ability to completely lavage all regions of the peritoneal cavity and the ability to detect cancer cells being shed into the peritoneal cavity by the tumor.
  • Direct visualization of the peritoneal surfaces along with palpation of the abdominal contents is by far the most sensitive modality for detecting peritoneal cancer. This can be accomplished with a minimally invasive approach (ie, laparoscopy), which allows for safe, directed peritoneal lavage for cytology and with open abdominal exploration and palpation of the peritoneal surfaces. Open abdominal exploration and palpation are extremely sensitive for 1- to 2-mm peritoneal nodules.

Histologic Findings

Primary peritoneal carcinoma is histologically indistinguishable from primary epithelial ovarian carcinoma; however, primary ovarian cancer can be excluded based on certain criteria. First, both ovaries must be of normal in size. Second, the extraovarian involvement must be greater than the involvement on the surface of the ovary. Third, the ovarian component must be smaller than 5 by 5 mm within the ovary or confined to the ovarian surface. Finally, the cytologic characteristics must be of the serous type.

More on Peritoneal Cancer

Overview: Peritoneal Cancer
Differential Diagnoses & Workup: Peritoneal Cancer
Treatment & Medication: Peritoneal Cancer
Follow-up: Peritoneal Cancer
References
[ CLOSE WINDOW ]

References

  1. Abeloff MD, Armitage JO, Lichter AS, Niederhuber JE. Clinical Oncology. 2nd ed. Philadelphia, Pa: Churchill Livingstone; 2000.

  2. Bani-Hani KE, Gharaibeh KA. Malignant peritoneal mesothelioma. J Surg Oncol. Jul 1 2005;91(1):17-25. [Medline].

  3. Biswas G, Laskar S, Banavali SD, Gujral S, Kurkure PA, Muckaden M, et al. Desmoplastic small round cell tumor: extra abdominal and abdominal presentations and the results of treatment. Indian J Cancer. Apr-Jun 2005;42(2):78-84. [Medline].

  4. Bodner K, Bodner-Adler B, Mayerhofer S, Grunberger W, Wierrani F, Czerwenka K, et al. Malignant fibrous histiocytoma (MFH) of the mesentery: a case report. Anticancer Res. Mar-Apr 2002;22(2B):1169-70. [Medline].

  5. Brigand C, Monneuse O, Mohamed F, Sayag-Beaujard AC, Isaac S, Gilly FN, et al. Peritoneal mesothelioma treated by cytoreductive surgery and intraperitoneal hyperthermic chemotherapy: results of a prospective study. Ann Surg Oncol. Mar 2006;13(3):405-12. Epub 2006 Jan 30. [Medline].

  6. Chang F. Desmoplastic small round cell tumors: cytologic, histologic, and immunohistochemical features. Arch Pathol Lab Med. May 2006;130(5):728-32. [Medline].

  7. Chouli M, Viala J, Dromain C, Fizazi K, Duvillard P, Vanel D. Intra-abdominal desmoplastic small round cell tumors: CT findings and clinicopathological correlations in 13 cases. Eur J Radiol. Jun 2005;54(3):438-42. [Medline].

  8. Clement PB. Reactive tumor-like lesions of the peritoneum. Am J Clin Pathol. Jun 1995;103(6):673-6. [Medline].

  9. Cormio G, Di Vagno G, Di Gesu G, Mastroianni M, Melilli GA, Vimercati A, et al. Primary peritoneal carcinoma: a report of twelve cases and a review of the literature. Gynecol Obstet Invest. 2000;50(3):203-6. [Medline].

  10. Deraco M, Casali P, Inglese MG, Baratti D, Pennacchioli E, Bertulli R, et al. Peritoneal mesothelioma treated by induction chemotherapy, cytoreductive surgery, and intraperitoneal hyperthermic perfusion. J Surg Oncol. Jul 2003;83(3):147-53. [Medline].

  11. Devita VT, Hellman S, Rosenthal SA. Cancer. In: Principles and Practice of Oncology. 7th ed. Philadelphia, Pa: Lippincott Williams & Wilkins (LWW); 2005.

  12. Gómez Portilla A, Cendoya I, Muriel J, Olabarria I, Guede N, Moraza N, et al. [Malignant peritoneal mesothelioma. Our experienced with triple combined therapy: cytoreduction, intraperitoneal perioperative chemotherapy and hyperthermia]. Cir Esp. Feb 2007;81(2):82-6. [Medline].

  13. Jaaback KS, Ludeman L, Clayton NL, Hirschowitz L. Primary peritoneal carcinoma in a UK cancer center: comparison with advanced ovarian carcinoma over a 5-year period. Int J Gynecol Cancer. Jan-Feb 2006;16 Suppl 1:123-8. [Medline].

  14. Kim HC, Lee JM, Kim SH, Kim KW, Lee M, Kim YJ, et al. Primary gastrointestinal stromal tumors in the omentum and mesentery: CT findings and pathologic correlations. AJR Am J Roentgenol. Jun 2004;182(6):1463-7. [Medline].

  15. Ko SF, Chou FF, Huang CH, Ng SH, Wan YL, Lee TY, et al. Primary synovial sarcoma of the gastrocolic ligament. Br J Radiol. Apr 1998;71(844):438-40. [Medline].

  16. Mohamed F, Sugarbaker PH. Peritoneal mesothelioma. Curr Treat Options Oncol. Oct 2002;3(5):375-86. [Medline].

  17. Nam JH, Kim YM, Jung MH, Kim KR, Yoo HJ, Kim DY, et al. Primary peritoneal carcinoma: experience with cytoreductive surgery and combination chemotherapy. Int J Gynecol Cancer. Jan-Feb 2006;16(1):23-8. [Medline].

  18. Ordóñez NG. Pathologic characterization and differential diagnosis of malignant peritoneal mesothelioma. Recent Results Cancer Res. 2007;169:123-36. [Medline].

  19. Papadatos D, Taourel P, Bret PM. CT of leiomyomatosis peritonealis disseminata mimicking peritoneal carcinomatosis. AJR Am J Roentgenol. Aug 1996;167(2):475-6. [Medline].

  20. Pavlidis N, Briasoulis E, Hainsworth J, Greco FA. Diagnostic and therapeutic management of cancer of an unknown primary. Eur J Cancer. Sep 2003;39(14):1990-2005. [Medline].

  21. Pickhardt PJ, Bhalla S. Primary neoplasms of peritoneal and sub-peritoneal origin: CT findings. Radiographics. Jul-Aug 2005;25(4):983-95. [Medline].

  22. Pickhardt PJ, Bhalla S. Unusual nonneoplastic peritoneal and subperitoneal conditions: CT findings. Radiographics. May-Jun 2005;25(3):719-30. [Medline].

  23. Popovska S, Veselinova T, Gorchev G, Tomov S, Elenchev L. [Primary peritoneal carcinoma: a report of two cases and a review of the literature]. Akush Ginekol (Sofiia). 2005;44(1):8-10. [Medline].

  24. Sebbag G, Shmookler BM, Chang D, Sugarbaker PH. Peritoneal carcinomatosis from an unknown primary site. Management of 15 patients. Tumori. Mar-Apr 2001;87(2):67-73. [Medline].

  25. Shen P, Levine EA, Hall J, Case D, Russell G, Fleming R, et al. Factors predicting survival after intraperitoneal hyperthermic chemotherapy with mitomycin C after cytoreductive surgery for patients with peritoneal carcinomatosis. Arch Surg. Jan 2003;138(1):26-33. [Medline].

  26. Stafford-Johnson DB, Bree RL, Francis IR, Korobkin M. CT appearance of primary papillary serous carcinoma of the peritoneum. AJR Am J Roentgenol. Sep 1998;171(3):687-9. [Medline].

  27. Sugarbaker PH, Acherman YI, Gonzalez-Moreno S, Ortega-Perez G, Stuart OA, Marchettini P, et al. Diagnosis and treatment of peritoneal mesothelioma: The Washington Cancer Institute experience. Semin Oncol. Feb 2002;29(1):51-61. [Medline].

  28. Suh-Burgmann E, Powell CB. Cytoreductive surgery for gynecologic malignancies-new standards of care. Surg Oncol Clin N Am. Jul 2007;16(3):667-82. [Medline].

  29. Szollosi A, Ferenc C, Pinter T, Erenyi A, Nagy A. [Benign cystic mesothelioma, a rare tumor of the peritoneum]. Magy Seb. Feb 2005;58(1):35-7. [Medline].

  30. Wong WL, Johns TA, Herlihy WG, Martin HL. Best cases from the AFIP: multicystic mesothelioma. Radiographics. Jan-Feb 2004;24(1):247-50. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

ovarian cancer, malignant mesothelioma, benign papillary mesothelioma, desmoplastic small round cell tumors, DSRCT, peritoneal angiosarcoma, leiomyomatosis peritonealis disseminata, LPD, peritoneal hemangiomatosis, primary peritoneal cancer, peritoneal malignancy, peritoneum, peritoneal carcinoma, peritoneal carcinoma, abdominal therapeutic radiation, radiation therapy, asbestos exposure, cystic mesothelioma, multilocular peritoneal inclusion cyst, primary peritoneal carcinoma, serous surface papillary carcinoma

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Wissam Bleibel, MD, Staff Physician, Department of Internal Medicine, Caritas Carney Hospital, Tufts University School of Medicine
Wissam Bleibel, MD is a member of the following medical societies: American Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Olga Kozyreva, MD, Fellow, Department of Hematology-Oncology, Tufts University School of Medicine
Disclosure: Nothing to disclose.

Sarah K May, MD, Consulting Staff, Department of Hematology-Oncology, Caritas Carney Hospital, Commonwealth Hematology-Oncology PC
Sarah K May, MD is a member of the following medical societies: American Society of Clinical Oncology
Disclosure: Nothing to disclose.

Daniel Efiom-Ekaha, MD, Fellow in Hematology/Oncology, Department of Internal Medicine, State University of New York-Downstate
Daniel Efiom-Ekaha, MD is a member of the following medical societies: American Medical Association
Disclosure: Nothing to disclose.

Arunbhai G Patel, MD, Chief, Department of Internal Medicine, Division of Hematology-Oncology, Brooklyn Hospital Center
Arunbhai G Patel, MD is a member of the following medical societies: American Medical Association
Disclosure: Nothing to disclose.

Adekunle Kuku, MD, Staff Physician, Department of Internal Medicine, Brooklyn Hospital Center
Disclosure: Nothing to disclose.

Medical Editor

Robert C Shepard, MD, FACP, Associate Professor of Medicine in Hematology and Oncology at University of North Carolina at Chapel Hill; Vice President of Scientific Affairs, Therapeutic Expertise, Oncology, at PRA International
Robert C Shepard, MD, FACP is a member of the following medical societies: American Association for Cancer Research, American College of Physician Executives, American College of Physicians, American Federation for Clinical Research, American Federation for Medical Research, American Medical Association, American Medical Informatics Association, American Society of Clinical Oncology, American Society of Hematology, Association of Clinical Research Professionals, Eastern Cooperative Oncology Group, European Society for Medical Oncology, Massachusetts Medical Society, and Society for Biological Therapy
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Benjamin Movsas, MD, Vice-Chairman, Department of Radiation Oncology, Fox Chase Cancer Center
Benjamin Movsas, MD is a member of the following medical societies: American College of Radiology, American Radium Society, American Society for Therapeutic Radiology and Oncology, and American Society of Clinical Oncology
Disclosure: Nothing to disclose.

CME Editor

Rajalaxmi McKenna, MD, FACP, Consulting Staff, Department of Medicine, Southwest Medical Consultants, SC, Good Samaritan Hospital, Advocate Health Systems
Rajalaxmi McKenna, MD, FACP is a member of the following medical societies: American Society of Clinical Oncology, American Society of Hematology, and International Society on Thrombosis and Haemostasis
Disclosure: Nothing to disclose.

Chief Editor

Jules E Harris, MD, Visiting Professor of Medicine, Division of Hematology/Medical Oncology, Department of Internal Medicine, University of Arizona College of Medicine at Tucson; Consulting Staff, Arizona Cancer Center
Jules E Harris, MD is a member of the following medical societies: American Association for Cancer Research, American Association for the Advancement of Science, American Association of Immunologists, American Federation for Clinical Research, American Society of Clinical Oncology, American Society of Hematology, Central Society for Clinical Research, Society for Biological Therapy, and Society for Leukocyte Biology
Disclosure: GlobeImmune Salary Consulting; Amplimed Consulting fee Consulting

RELATED MEDSCAPE ARTICLES
 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.