Peritoneal Cancer Workup
- Author: Wissam Bleibel, MD; Chief Editor: N Joseph Espat, MD, MS, FACS more...
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.
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- 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; rather than relying on solid tumor detection, therefore, it is important to consider findings that may suggest the presence of peritoneal lesions. 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, diffuse enhancement with nodular thickening of the parietal peritoneum of the pelvis, and normal-sized ovaries, with or without a fine enhancing surface nodularity of the ovary.
- Malignant peritoneal mesotheliomas produce CT findings that range from peritoneum-based masses (a so-called "dry" appearance) to ascites, irregular or nodular peritoneal thickening, and an omental mass (a so-called "wet" appearance). Scalloping of the peritoneum or direct invasion of adjacent abdominal organs may also be seen.
- 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.
- Dual-time point imaging after carbonated water may increase the accuracy of 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT for the imaging of peritoneal cancer in patients affected by colon rectal cancer.
- 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 that may be considered when radionuclide scans, CT scan, and ultrasound findings are negative.
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- The workup of peritoneal lesions includes peritoneal lavage cytology. Peritoneal lavage can be performed using a percutaneous 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, or 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.
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 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.
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