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ABDOMINAL AND GASTROINTESTINAL RADIOLOGY Table of Contents   
Year : 2010  |  Volume : 20  |  Issue : 1  |  Page : 58-62
CT mimics of peritoneal carcinomatosis


Department of Radio-diagnosis and Imaging, Kasturba Medical College, Manipal, Karnataka, India

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Date of Web Publication6-Feb-2010
 

   Abstract 

Peritoneal carcinomatosis is a term used to describe widespread metastases of cancerous tumors in the peritoneal cavity. It is most common in carcinomas of the gastrointestinal tract (GIT) and ovaries, and must be considered to be the main diagnosis even when the primary is not known. A wide variety of disease processes mimic peritoneal carcinomatosis. Precise diagnosis based on imaging alone is often difficult and very often the final diagnosis is only obtained after appropriate histopathology or microbiology.

Keywords: Carcinomatosis; neoplastic; peritoneal

How to cite this article:
Smiti S, Rajagopal K V. CT mimics of peritoneal carcinomatosis. Indian J Radiol Imaging 2010;20:58-62

How to cite this URL:
Smiti S, Rajagopal K V. CT mimics of peritoneal carcinomatosis. Indian J Radiol Imaging [serial online] 2010 [cited 2019 Nov 22];20:58-62. Available from: http://www.ijri.org/text.asp?2010/20/1/58/59757

   Introduction Top


Peritoneal carcinomatosis is a metastatic manifestation of many organ-based malignancies, particularly carcinomas of the gastrointestinal tract (GIT) and ovaries, and must be considered as the first possibility even in the absence of a known primary. There are several neoplastic and non-neoplastic conditions that may mimic peritoneal carcinomatosis on CT scan. These include lymphomas, gastrointestinal stromal tumors (GIST), granulomatous infections like tuberculosis, and primary peritoneal malignancies such as mesotheliomas.


   Discussion Top


Peritoneal carcinomatosis

Peritoneal carcinomatosis without distant metastases represents locoregional disease and calls for aggressive locoregional treatment. Most CT scan findings are however nonspecific as both neoplastic and non-neoplastic pathologies of the peritoneum present as soft-tissue masses, with or without ascites. [1] In addition, there may also be a cystic component, necrosis, calcification, or significant contrast enhancement. Sometimes, peritoneal nodules can simulate unopacified bowel loops and hence adequate bowel opacification is important for accurate diagnosis. [2] The CT appearance of neoplastic infiltration of the greater omentum can range from increased density of fat anterior to the colon or small bowel, to large masses, called omental cakes, separating the colon and small bowel from the anterior abdominal wall, [Figure 1].

Very often though, the diagnosis is relatively easy when associated ovarian [Figure 2]a and b or gastric neoplastic disease is seen. In the absence of a primary neoplasm and sometimes even in the presence of ovarian or gastric and bowel masses, other disease entities such as GIT lymphomas, GIST of the omentum and mesentery, peritoneal tuberculosis, and primary neoplasms of the peritoneum like primary peritoneal mesothelioma, can all mimic peritoneal carcinomatosis.

This pictorial essay is based on our experience with patients with CT features that mimicked peritoneal carcinomatosis; in all cases, the diagnosis was confirmed on histopathology.

Lymphoma

Peritoneal lymphomatosis due to GIT lymphoma may be seen on CT as omental caking or masses, with diffuse peritoneal thickening [Figure 3]a or ascites. [3] Associated findings that may help in distinguishing lymphoma from peritoneal carcinomatosis include aneurysmal dilatation of a bowel segment, with a thickened wall [Figure 3]b and c and splenic enlargement [4] [Figure 4]. The classic appearance on CT is of confluent masses causing encasement of the superior mesenteric artery and vein, producing a 'sandwich sign'; [5] these masses are bulky, soft, non-obstructing neoplasms [Figure 5]a and b, with a tendency to be less vascular than carcinomas. There is usually homogenous attenuation, without significant necrosis with marked bowel wall thickening. The differential diagnosis of mesenteric lymphadenopathy also includes metastases and reactive lymphadenopathy due to granulomatous infections, Crohn disease, etc. [2] Splenic involvement and large non-necrotic masses and lymph nodes help make this diagnosis.

Primary peritoneal mesothelioma

Malignant primary peritoneal mesothelioma, though rare, can be seen as a large confluent mass [Figure 6]a, which may be nodular or diffuse, with or without ascites [Figure 6]b. Calcification is uncommon. [1] Approximately 30% arise primarily from the peritoneum, with the rest arising from the pleural surface. It can cause scalloping of, or a mass effect on, adjacent abdominal organs. A history of exposure to asbestos is found in a few cases. Unlike in pleural mesothelioma, associated calcified peritoneal plaques are uncommon. High-power microscopy may show hyperchromatic nuclei and large cells with peripheral dense cytoplasm.

Gastrointestinal stromal tumors

GIST refers to tumors arising from the mesenchymal tissue of the GIT; they commonly possess spindle cells and show c-kit protein positivity. [6] Although c-kit expression may be seen in other malignant tumors, it has a high specificity for GIST. GIST is often solitary and arises most commonly from the stomach (60-70%), followed by small bowel (20- 25%) and, rarely, the rectum (5%), esophagus, colon, and appendix. [3] GIST is rarely seen arising from the mesentery, omentum, and retroperitoneum and is usually large in size at the time of presentation. It may sometimes be an incidental finding owing to the submucosal origin of the tumor and exophytic nature of the tumor growth. [7]

GIST of the omentum and mesentery may present with diffuse peritoneal seeding, mimicking mesenteric carcinomatosis. In a study by Kim et al., primary GIST in the omentum and mesentery were seen as well-circumscribed, large masses containing areas of hemorrhage, necrosis [Figure 7]a, or cystic degeneration. [8] Peritoneal deposits may also be seen [Figure 7]b. One differentiating feature of GIST is their hypervascularity because of which, even if central necrosis or cystic degeneration is present, there may be peripheral enhancement with surrounding dilated vessels. [9]

Peritoneal tuberculosis

Peritoneal tuberculosis, in particular, can be a difficult and elusive diagnosis to make and may mimic metastases from ovarian cancer and other nontuberculous granulomatous diseases because of the vague symptoms and nonspecific radiographic, pathologic, and laboratory findings. Tuberculous peritonitis may be of wet, fixed fibrotic, and dry plastic types. [10] The wet type presents as free or loculated ascites with septae. The fixed fibrotic type may present as an omental and mesenteric mass, with matted bowel loops, and the dry plastic type can show thickened peritoneum and necrotic lymph nodes, though there is often an overlap between these two types. [2] A high index of suspicion for peritoneal tuberculosis is important if unnecessary elaborate surgery and delay in treatment are to be avoided. [11] The CT scan findings include omental cake-like masses [Figure 8], nodules, [10] and a smudge pattern. The peritoneal thickening is usually smooth as compared to the nodularity seen in peritoneal carcinomatosis. [12] Peritoneal tuberculosis can mimic peritoneal carcinomatosis [Figure 9]. A few cases of abdominal tuberculosis may even show elevation of CA 125. The presence of necrotic mesenteric and retroperitoneal lymph nodes, especially in younger patients helps clinch this diagnosis.

Other lesions such as papillary serous carcinoma, desmoplastic small round-cell tumor, and mesenchymal tumors, including both benign and malignant tumors may occur but are difficult to diagnosis on imaging findings alone.

CT scan plays an important role in the detection of peritoneal carcinomatosis and its mimics. However, the exact diagnosis and characterization of lesions may be difficult due to the overlap of imaging findings. CT scan can also play an important role in guiding biopsy for tissue diagnosis and can provide the surgeon with a 'road map' prior to cytoreductive surgery. Since a precise diagnosis based on imaging findings alone is often not possible, histopathology is mandatory to confirm the diagnosis.


   Acknowledgement Top


We acknowledge our sincere thanks to Dr. V.R.K. Rao, Head of Department of Radio-diagnosis, Kasturba Medical College, Manipal for his constant support.

 
   References Top

1.Pickhardt PJ, Bhalla S. Primary neoplasms of peritoneal and sub- peritoneal origin: CT Findings - Radiographics 2005;25:983-95.  Back to cited text no. 1      
2.Balachandran A, Silverman PM. Mesenteric and Omental lesions. In: Gore and Levine, editors. Textbook of Gastrointestinal radiology. 3 rd ed. Saunders; vol. 2. 2143 and 2139.  Back to cited text no. 2      
3.Gollub MJ. Imaging of gastrointestinal lymphoma. Radiol Clin North Am 2008;46:287-312.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]  
4.Horger M, Müller-Schimpfle M, Yirkin I, Wehrmann M, Claussen CD. Extensive peritoneal and omental lymphomatosis with raised CA 125 mimicking carcinomatosis: CT and intraoperative findings. Br J Radiol 2004;77:71-3.  Back to cited text no. 4      
5.Hardy SM. The Sandwich sign. Radiology 2003;226:651-2.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]  
6.Miettinen M, Lasota J. Gastrointestinal stromal tumors-definition, clinical, histological, immunohistochemical, and molecular genetic features and differential diagnosis. Virchows Arch 2001;438:1-12.  Back to cited text no. 6  [PUBMED]  [FULLTEXT]  
7.Lau S, Tam KF, Kam CK, Lui CY, Siu CW, Lam HS, et al. Imaging of gastrointestinal stromal tumour (GIST). Clin Radiol 2004;59:487-98.  Back to cited text no. 7      
8.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 2004;182:1463-7.  Back to cited text no. 8      
9.Yang TH, Hwang JI, Hung SW, Wang RC, Lee T,Tyan YS Gastrontestinal stromal tumour of omentum and mesentery mimicking peritoneal carcinomatosis: A case report. Chin J Radiol 2006;31:53-8.  Back to cited text no. 9      
10.Akhan O, Pringot J. Imaging of abdominal tuberculosis. Eur Radiol 2002;12:312-23.  Back to cited text no. 10  [PUBMED]  [FULLTEXT]  
11.Mahdavi A, Malviya VK, Herschman BR. Peritoneal tuberculosis disguised as ovarian cancer: An emerging clinical challenge. Gynecol Oncol 2002;84:167-70.  Back to cited text no. 11  [PUBMED]  [FULLTEXT]  
12.Lee DH, Lim JH, Ko YT, Yoon Y. Sonographic findings in tuberculous peritonitis of wet-ascitic type. Clin Radiol 1991;44:306-10.  Back to cited text no. 12  [PUBMED]  [FULLTEXT]  

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Correspondence Address:
S Smiti
Department of Radio-diagnosis and Imaging, Kasturba Medical College, Manipal - 576 104, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-3026.59757

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]

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