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): WNL, Bil. Adnexa: invisible Colonoscopy (2008/9/26): internal hemorrhoid U/A: normal CT of abdomen and pelvis (2009/10/29):

Peritoneal carcinomatosis Omental thickening (Omental cake) nodularity

Omental thickening (Omental cake) nodularity

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 Tumor marker 為GI doctor 開單

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

Omental thickening

Omental thickening

Omental thickening

Case 1: History Impression: Primary peritoneal carcinoma Laparotomy (2008/11/13): Large omental cake adhesion to anterior peritoneal layer Some ascites < 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) Suggest laparotomy ny GYN DOCTOR Impression : primary peritoneal carcinoma

Case 1: History Operative procedures: Pathology: 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)

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

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

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

Case 2: History 2009/4/29: CA-125: 93.71 U/ml (normal < 35) Breast echo: normal Gyn echo: R’t ovary : 1.94 x 1.46 cm L’t ovary : unremarkable Adenomyosis of uterus 健檢 PES, colonoscopy, breast echo, abd echo, Gyn echo, CTA, low dose CT

2009/6/23

Omental thickening Omental thickening

Omental thickening Cul-de-sac

Cul-de-sac Omental thickening

Omental thickening

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

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

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)

Discussion

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

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

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

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

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

Bil. Ovarian cancer with peritoneal seeding

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

Peritoneal seeding to Morison’s pouch

Peritoneal seeding to falciform ligment

Peritoneal seeding to subdiaphragmatic surface

Rectal cancer with abdominal wall and bowel loop involvement 53 y/o male Rectal cancer s/p LAR and CCRT

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

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

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

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

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

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

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

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.

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.

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

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

Omental thickening (Omental cake) nodularity

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

CA-125 & Ovarian Cancer The average reported sensitivities for ovarian cancer: 50% for stage I 90% for stage II or higher disease Varies according to histology Specificity of CA 125 is limited. Rarely > 100~200 U/ml in benign conditions. From UpToDate; Epithelial ovarian cancer : Clinical manifestations, diagnostic evaluation, staging, and histopathology

CA-125 & Ovarian Cancer Not a useful diagnostic test in premenopausal women, especially at low positive levels (warning if > 200 U/ml). It is more useful in postmenopausal women, in whom the positive predictive value for malignancy is 97 %.

CA-125 & Ovarian Cancer High preoperative CA-125 levels correlate with: Advanced stage (III or IV) High grade disease Serous histology The presence of ascites

CA-125 & Ovarian Cancer Not a reliable predictor of the likelihood of optimal cytoreduction. Baseline measurement is useful in evaluating the success of subsequent treatment.

CA 125 & Ovarian Cancer A pelvic mass suspicious for malignancy if: Ascites Nodularity/fixation Evidence of metastases A First degree relative with ovarian or brest cancer Elevated CA-125 level (normal < 35) Any abnormal in the postmenopausal A level > 200 U/ml in the premenopausal American College of Obstetricians and Gynecologists

Conclusion Peritoneal carcinomatosis occurs commonly with abdominopelvic tumors. FDG-PET/CT has the potential to improve detection of peritoneal carcinomatosis. But there are limits. In normal-sized ovarian carcinoma syndrome, peritoneal carcinomatosis is noted, despite of normal size of ovaries.

Conclusion Elevation serum CA-125 ( any abnormal in the postmenopausal, and > 200 U/ml in the premenopausal) can help in the diagnosis of ovarian cancer.

Thank You