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Imaging	
  of	
  peritoneal	
  
carcinomatosis	
  
C.HOEFFEL,	
  Reims	
  
P.ROUSSET,	
  Lyon	
  
	
  
HANOI,	
  NOV	
  2015	
  
ObjecHves	
  
•  Understand	
  why	
  evaluaHon	
  of	
  carcinomatosis	
  is	
  
necessary	
  
•  Understand	
  where	
  to	
  look	
  for	
  and	
  how	
  to	
  
quanHfy	
  carcinomatosis	
  
•  Know	
  the	
  protocol	
  of	
  CT	
  and	
  MR	
  examinaHons	
  
for	
  evaluaHon	
  of	
  carcinomatosis	
  
•  Know	
  the	
  role	
  and	
  added	
  value	
  of	
  involved	
  
imaging	
  modaliHes	
  in	
  evaluaHon	
  of	
  
carcinomatosis	
  
General	
  consideraHons	
  
•  Primary	
  
– GI	
  :	
  colo-­‐rectal,	
  pancreaHc,	
  gastric	
  
– Ovary/Breast	
  
•  Outcome	
  
– Median	
  survival:	
  7	
  months,	
  OS-­‐2	
  years	
  :	
  	
  15%	
  
– Limited	
  penetraHon	
  of	
  systemic	
  
chemotherapy	
  
	
  
•  New	
  agressive	
  treatment=	
  standard	
  [	
  for	
  paHents	
  
with	
  disease	
  confined	
  to	
  peritoneum	
  and	
  CRC	
  
–  Removal	
  of	
  macroscopical	
  	
  	
  
–  HIPEC:	
  high	
  local	
  concentraHon	
  of	
  	
  chemotherapy,	
  increased	
  in	
  drug	
  toxicity	
  
with	
  heat,	
  for	
  microscopical	
  
–  OS-­‐3	
  years:	
  53	
  %	
  and	
  OS-­‐5	
  years:	
  48.5	
  %	
  
–  30	
  %	
  morbidity,	
  4	
  %	
  mortality	
  
General	
  consideraHons	
  
ROLE	
  OF	
  IMAGING	
  
•  Not	
  only	
  Diagnosis	
  but	
  
•  Extension	
  for	
  strategy	
  –	
  selecHon	
  of	
  paHents	
  for	
  
surgery	
  +++,	
  even	
  if	
  perop	
  evaluaHon=	
  ref	
  
–  PCI	
  =	
  peritoneal	
  cancer	
  index=>	
  score	
  0	
  to	
  39	
  (12	
  regions),	
  	
  
ex	
  Sugarbaker	
  score	
  
•  Diameter	
  :	
  score	
  1	
  =	
  0-­‐5	
  mm,	
  score	
  2=	
  5	
  mm-­‐5	
  cm,	
  score	
  
3	
  >	
  5	
  cm	
  
–  Probability	
  to	
  obtain	
  R0	
  surgery	
  	
  and	
  	
  taken	
  into	
  account	
  as	
  
CI	
  to	
  surgery	
  when	
  too	
  high	
  for	
  a	
  type	
  of	
  cancer	
  
Sugarbaker PH, De Bree E., Jour Surg Oncol, 2004
•  Extension	
  necessitaHng	
  expert	
  centre:	
  
–  ResecHon	
  of	
  diaphragm	
  for	
  diaphragmaHc	
  nodule	
  
–  HepaHc	
  parenchymal	
  invasion	
  from	
  implants,	
  Bowel	
  
implants	
  	
  
–  Bladder	
  or	
  ureteral	
  invasion	
  
•  Idea	
  of	
  length	
  and	
  morbidity	
  
•  No	
  current	
  consensus	
  on	
  criteria	
  for	
  subopHmal	
  
resecHon	
  but	
  some	
  lesions	
  suggest	
  non	
  resectability	
  
	
  
ROLE	
  OF	
  IMAGING	
  
Low AJR 2008 Low. Ann Surg Oncolo.2013 Nougaret.	
  Radiographics	
  2013	
  
 
Alert	
  surgeons	
  to	
  to	
  the	
  presence	
  of	
  disease	
  that	
  may	
  complicate	
  surgery	
  or	
  may	
  
preclude	
  opHmal	
  debulking	
  .	
  	
  
Extensive	
  involvement	
  of	
  small	
  bowel-­‐	
  diffuse	
  mesenteric	
  infiltraHon	
  or	
  retracHon	
  
of	
  the	
  root	
  of	
  mesentery	
  
	
  
C Hoeffel, P Rousset imaging of peritoneal carcinomatosis jfim hanoi 2015
•  Bulky	
  hepatoduodenal-­‐	
  involved	
  node	
  sup	
  to	
  celiac	
  axis	
  
•  Involvement	
  of	
  vesical	
  trigone	
  -­‐	
  pelvic	
  sidewall	
  
Non	
  mucinous	
  CRC-­‐	
  not	
  resectable	
  because	
  involvement	
  of	
  duodenal	
  extension	
  
•  IdenHfy	
  extraperitoneal	
  lesions	
  
– Liver	
  small	
  or	
  central	
  mets	
  in	
  liver	
  ,	
  spleen	
  not	
  seen	
  with	
  lap	
  
– Lymph	
  nodes	
  
– Abdominal	
  wall	
  
– Pleura	
  
– Bone	
  
Role	
  of	
  Imaging	
  
 
– Liver	
  
– Lymph	
  nodes	
  
– Abdominal	
  wall	
  	
  
– Pleura-­‐	
  inaccessible	
  with	
  lap	
  
– Bone	
  
 	
  
	
  
– Liver	
  
– Lymph	
  nodes	
  
– Abdominal	
  wall	
  	
  
– Pleura-­‐	
  inaccessible	
  with	
  lap	
  
– Bone	
  
Where	
  to	
  look	
  for	
  carcinosis?	
  
– Gravity	
  dependent	
  areas	
  or	
  of	
  arrested	
  flows	
  	
  
•  Pelvic	
  recesses	
  (rectouterine,	
  lateral	
  paravesical,	
  RLQ),	
  
Right	
  paracolic	
  	
  gu[er	
  (phrenicocolic	
  lig	
  upward	
  on	
  the	
  
lel),	
  ACE,	
  Morisson’s	
  recess,	
  Right	
  subdiaphragmaHc	
  
space	
  	
  
•  RS	
  J,	
  Ileocaecal	
  juncHon,	
  pylorus	
  
– Peritoneal	
  folds	
  containing	
  fat	
  
•  Ligaments	
  :	
  reflexion	
  area	
  between	
  visceral	
  and	
  parietal	
  	
  p	
  	
  	
  
•  Mesos	
  :	
  mesentery,	
  transverse	
  meso	
  colon,	
  mesosigmoïd	
  
•  Omentum	
  	
  
	
   Nougaret	
  et	
  al.	
  RadioGraphics	
  2012.	
  32,	
  No.	
  6:	
  1775-­‐1800	
  
PCI	
  	
  SCORE-­‐Features	
  
	
  
	
  	
  
•  	
  Involvement	
  of	
  parietal	
  serosa	
  :	
  peritoneal	
  
thickening-­‐	
  nodules	
  
•  	
  Involvement	
  of	
  fa[y	
  areas	
  (omental	
  cake)	
  
	
  
Nougaret	
  et	
  al.	
  RadioGraphics	
  2012	
  Vol.	
  32,	
  No.	
  6:	
  1775-­‐1800	
  
plaques
infiltration
Reticulonodular lesions
Mass (confluent nodules)
•  	
  Involvement	
  of	
  visceral	
  serosa	
  	
  
– Extrinsic	
  tumoral	
  infiltraHon	
  (ileocaecal,	
  right	
  
colonic	
  angle,	
  RSJ)	
  
– Distorsion	
  SB	
  	
  (retracHon	
  of	
  mesentery)-­‐	
  
Thickening	
  
– ObstrucHon	
  
PCI SCORE-Features
Pr Valette PJ. Lyon
 
Adhesions=	
  deviaHon	
  of	
  a	
  structure	
  to	
  another	
  or	
  thickening	
  between	
  
two	
  structures	
  without	
  fat	
  interface.	
  	
  
	
  
 
nodules	
  of	
  the	
  mesentery	
  if	
  >7mm,	
  and/if	
  irregular	
  hypodense	
  nodules	
  
and/if	
  numerous	
  :	
  grouped	
  and	
  >	
  8	
  on	
  one	
  slice	
  	
  	
  
	
  
Other	
  signs	
  
•  Ureteral	
  dilataHon	
  
without	
  any	
  obstacle	
  	
  
•  Cardiophrenic	
  lymph	
  
node	
  	
  
– 550	
  pts	
  with	
  CRC	
  
– 30	
  %	
  proven	
  PC	
  
– VPN	
  85	
  %/VPP	
  49	
  %	
  
	
  
Caramella.	
  Eur	
  J	
  Cancer	
  2013	
  
Two years after surgery for CRC.
Ureteral dilatation due to carcinomatosis
Pseudomyxoma	
  
•  Intraperitoneal	
  seeding	
  of	
  mucin	
  secreHng	
  cells	
  responsible	
  for	
  mucin	
  in	
  
the	
  peritoneum	
  
–  Low	
  grade	
  and	
  high	
  grade	
  according	
  to	
  OMS	
  2010	
  
–  From	
  mucinous	
  appendicular,	
  ovary	
  	
  
•  Features:	
  
–  Diffuse	
  involvement	
  	
  
–  Thick	
  asciHs	
  with	
  scalloping	
  or	
  septas	
  
–  Possibility	
  of	
  calcificaHons	
  
–  Rarely	
  	
  nodules	
  and	
  masses,	
  associated	
  organ	
  involvement	
  or	
  extent	
  to	
  
pleura	
  
ROLE	
  of	
  CT	
  
•  Reference	
  imaging	
  for	
  staging	
  and	
  restaging	
  of	
  paHents:	
  	
  
	
  	
  >90	
  %	
  /paHent	
  
•  Easily	
  available,	
  quick,	
  large	
  FOV	
  	
  
	
  
–  SpaHal	
  resoluHon	
  (1	
  mm	
  thick	
  slices)	
  and	
  3D	
  reformats:	
  reconstrucHon	
  
using	
  3	
  mm	
  slices-­‐	
  
–  Anayze	
  coronal	
  reformats	
  :	
  Nodule	
  in	
  at	
  least	
  two	
  planes	
  increases	
  confidence	
  in	
  
diagnosis	
  
•  Protocol:	
  IV	
  +±1	
  l	
  water	
  	
  
	
  IV-­‐	
  for	
  ovary	
  and	
  CRC	
  (30	
  %	
  with	
  calcificaHons)	
  
	
  
Chandrashekhara.	
  BJR.2011	
  
Mazzei	
  2013.	
  Abdominal	
  imaging	
  
 	
  	
  
	
  
•  PCI:	
  underscores	
  staging	
  
compared	
  with	
  surgery	
  
•  Depends	
  on	
  size	
  
– Se	
  <	
  15%	
  for	
  T<	
  0.5	
  cm	
  
(miliary	
  in	
  liniHs)	
  
– Se	
  <	
  25%	
  for	
  T	
  <	
  1	
  cm	
  	
  	
  
– Se	
  around	
  40%	
  for	
  T	
  =	
  0.5	
  -­‐	
  5	
  
cm	
  
– Se	
  60	
  to	
  94%	
  for	
  T	
  >	
  5	
  cm	
  
	
  
	
  
	
  De	
  Bree.	
  JSO	
  2004	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  Koh	
  Ann.	
  Surg	
  Oncol	
  .2009	
  	
  	
  	
  	
  	
  
Esquivel.	
  JSO	
  2010	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  Sala.	
  Radiology.	
  2010	
  	
  
ROLE	
  OF	
  CT-­‐	
  Limits	
  
small lesion on mesentery
plaque like lesion
ROLE	
  OF	
  CT-­‐	
  Limits	
  
•  Depends	
  on	
  site	
  	
  	
  
–  	
  Se<	
  20%	
  for	
  small	
  bowel	
  and	
  mesentery	
  	
  
–  Se	
  poor	
  for	
  diaphragmaHc	
  lesions	
  
–  Se	
  variable	
  for	
  pelvis	
  
•  Depends	
  on	
  level	
  of	
  experience	
  
•  Depends	
  on	
  type	
  of	
  	
  lesion	
  :	
  nodule	
  (k=0.8)/	
  
thickening	
  (k=0.4)/distorsion	
  (k=0.2)	
  
•  Depends	
  on	
  	
  amount	
  of	
  fat	
  	
  
De	
  Bree.	
  JSO.	
  2004	
  
ROLE	
  OF	
  CT-­‐	
  Limits	
  
•  	
  CharacterizaHon	
  of	
  nodules	
  and	
  of	
  asciHs	
  
Role	
  of	
  CT-­‐Limits	
  
Limits=	
  specificity	
  
ROLE	
  OF	
  MRI	
  
•  Few	
  studies	
  available,	
  parHcularly	
  in	
  paHents	
  without	
  
neoadjuvant	
  treatment	
  
•  MRI	
  versus	
  CT	
  
–  Qayyum.	
  Gynecol	
  oncol	
  2005:	
  137	
  pts,	
  CT	
  =	
  MRI	
  	
  
–  Torkzad.	
  JSO	
  2015:	
  39	
  pts,	
  PCI	
  radio	
  CT	
  =	
  MRI,	
  EXCEPT	
  junior	
  
–  Low.	
  Ann	
  surg	
  oncol.	
  2015:	
  22	
  pts:	
  Acc	
  =	
  85	
  vs	
  63%	
  
•  MRI	
  versus	
  PET	
  
–  Soussan.	
  Eur	
  radiol	
  2012:	
  30	
  pts	
  (13/33	
  (43%	
  opérés)	
  
	
   	
   	
   	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  Ac	
  =	
  83	
  vs	
  80%	
  per	
  p[	
  	
  
	
   	
   	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  per	
  site	
  MRI	
  +	
  per	
  lesion	
  
–  Klumpp.	
  abdo	
  imaging	
  2012:	
  15	
  pts:	
  88	
  vs	
  94%.	
  MRI	
  without	
  diffusion	
  
	
  	
  
•  MRI	
  alone	
  –	
  pseudomyxoma	
  
–  Low.	
  Ann	
  Surg	
  Oncol	
  2012:	
  33	
  p[s	
  (25	
  PMP)	
  	
  Acc	
  0.84	
  
MR	
  PROTOCOL	
  
•  Fast/PEG	
  500	
  cc?	
  	
  
•  AnHperistalHc	
   agents	
   before	
   gadolinium	
   injecHon	
   =	
  
glucagon	
  
•  MRI	
  of	
  abdomen	
  and	
  pelvis	
  -­‐	
  2	
  stacks	
  to	
  cover	
  the	
  
whole	
  peritoneal	
  cavity	
  	
  
– Axial	
  T2	
  single	
  shot	
  FSE	
  (trigger	
  free	
  breathing,	
  not	
  
as	
  good	
  with	
  echo	
  nav),	
  5-­‐6	
  mm,	
  sans	
  Fatsat	
  
– Axial	
  Diffusion	
  (b	
  0-­‐800)	
  	
  
– Axial	
  post	
  gadolinium-­‐enhanced	
  T1-­‐weighted	
  art/
portal/late	
  phase	
  (5	
  minutes).	
  	
  
T2	
  :	
  	
  Added	
  value	
  for	
  PCI	
  assessment	
  
•  	
  limited	
  added	
  value	
  in	
  non	
  mucinous	
  lesions	
  
T2	
  :	
  	
  Added	
  value	
  for	
  PCI	
  
assessment	
  
•  	
  added	
  value	
  ++	
  for	
  mucinous	
  lesions	
  
Gadolinium:	
  Added	
  value	
  for	
  PCI	
  assessment	
  
•  non	
  mucinous	
  lesions-­‐	
  peritoneal	
  thickening	
  
Gadolinium: Added value for PCI
assessment	
  
 
Gadolinium:	
  Added	
  value	
  for	
  PCI	
  
assessment	
  
	
  
Mucinous lesions
Tissu sain Tissu tumoral
	
  Diffusion:	
  Added	
  value	
  for	
  PCI	
  
assessment-­‐Contrast	
  resoluHon-­‐
detecHon	
  
Diffusion:	
  Added	
  value	
  for	
  PCI	
  
assessment-­‐DetecHon	
  
	
  
Diffusion:	
  non	
  mucinous	
  lesions-­‐	
  added	
  value	
  
parHcularly	
  for	
  difficult	
  areas	
  with	
  CT	
  
Low	
  -­‐	
  AJR	
  2009	
  :	
  	
  255	
  sites	
  lésionnels	
  
n  Standard	
  MRI 	
  se	
  73	
  -­‐	
  52%,	
  sp	
  92%	
  (k	
  =	
  0,67)	
  
n  Diffusion	
  b	
  =	
  500	
  se	
  71	
  -­‐	
  71%,	
  sp	
  90%	
  (k	
  =	
  0,67)	
  
n  MR	
  conv.	
  +	
  Diff	
  	
  	
  se	
  90	
  -­‐	
  84%,	
  sp	
  91%	
  (k	
  =	
  0,77)	
  
	
  
C Hoeffel, P Rousset imaging of peritoneal carcinomatosis jfim hanoi 2015
C Hoeffel, P Rousset imaging of peritoneal carcinomatosis jfim hanoi 2015
Small	
  bowel	
  serosa	
  
	
  	
  <	
  5	
  mm	
  
Added	
  value	
  for	
  pelvis	
  
	
  and	
  small	
  bowel	
  
WARN	
  SURGEON	
  =>	
  morbidity	
  
 
Abdominal	
  wall	
  lesion	
  	
  <	
  10	
  mm	
  
Added	
  value	
  for	
  special	
  sites	
  
	
  such	
  as	
  abdominal	
  wall	
  
Diffusion:	
  Added	
  value	
  for	
  PCI	
  
assessment-­‐CharacterizaHon	
  
Diffusion-­‐Limits	
  
•  Limits	
  of	
  diffusion	
  sequences	
  
–  T2	
  shine	
  through	
  effect=>	
  ADC	
  
–  RestricHon	
  of	
  diffusion	
  from	
  less	
  cellular	
  some	
  lesion:	
  
mucin,	
  adhesions,	
  confluent	
  areas,	
  fibrosis	
  
–  Lesions	
  with	
  blood,	
  mucoid	
  content	
  
MR	
  Technique-­‐Limits	
  
•  PaHent-­‐dependent	
  
•  PeristalHsm	
  
•  Black	
  hole	
  effect-­‐	
  get	
  rid	
  of	
  the	
  asciHs	
  before	
  
MRI	
  
•  ParHal	
  volume	
  effect-­‐spaHal	
  resoluHon	
  
•  Interobserver	
  Variability	
  (per	
  site)-­‐	
  learning	
  
curve	
  
	
  	
  
PET	
  CT-­‐	
  Main	
  IndicaHons	
  
•  Strong	
  Clinical	
  suspicion	
  of	
  PC	
  or	
  increase	
  in	
  markers	
  
level	
  with	
  normal	
  CT	
  
•  DetecHon	
  of	
  recurrence	
  versus	
  fibrosis	
  	
  
•  Assessment	
  before	
  HIPEC	
  	
  
–  Underscores	
  PCI	
  but	
  complementary	
  to	
  CT/MRI	
  	
  
–  Rules	
  out	
  extraperitoneal	
  lesions	
  contraindicaHng	
  surgery	
  	
  
–  False	
  negaHve	
  
•  Mucinous	
  tumors,	
  low	
  grade	
  pseudomyxoma	
  and	
  	
  gastric	
  liniHs	
  	
  	
  
PET	
  CT-­‐	
  Limits	
  
Passot.Eur	
  J	
  Surg	
  Oncol.	
  2010	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  Anthony.	
  AJR.2009	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  Hymnimen.	
  Gynecol	
  oncol.	
  2013	
  
PET	
  CT-­‐	
  Limits	
  
•  False	
  negaHve	
  
–  Size	
  <	
  1cm	
  
–  Hidden	
  lesions	
  by	
  respiratory	
  and	
  GI	
  movements	
  
•  False	
  posiHve:	
  specificity	
  <	
  CT	
  
–  Inflammatory	
  reacHon	
  of	
  peritoneum	
  around	
  large	
  or	
  numerous	
  implants	
  	
  
–  Foreign	
  body	
  or	
  inflammatory	
  reacHon	
  related	
  to	
  previous	
  surgery	
  	
  
–  Physiological	
  uptake	
  of	
  bowel	
  and	
  vessels	
  
	
  
	
  
	
  
Pierandrea	
  de	
  Iaco.	
  EJR.	
  2011	
  
Conclusion	
  
–  CT=	
  reference	
  imaging	
  	
  	
  
–  Before	
  	
  deciding	
  upon	
  treatment	
  
MRI	
  ±PET	
  scanner	
  needed	
  	
  
•  For	
  assessment	
  of	
  PCI	
  
•  Detect	
  lesions	
  needing	
  expert	
  
center	
  
•  Detect	
  non	
  resectable	
  disease	
  
–  Added	
  value	
  of	
  diffusion	
  for	
  small	
  
bowel,	
  pelvis	
  ,	
  hepaHc	
  hilum,	
  
pseudomyxoma	
  ++	
  
–  PET/CT	
  for	
  extraperitoneal	
  disease	
  
–  COMBINE	
  modaliHes	
  
Peritoneal	
  Thickening	
  

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C Hoeffel, P Rousset imaging of peritoneal carcinomatosis jfim hanoi 2015

  • 1. Imaging  of  peritoneal   carcinomatosis   C.HOEFFEL,  Reims   P.ROUSSET,  Lyon     HANOI,  NOV  2015  
  • 2. ObjecHves   •  Understand  why  evaluaHon  of  carcinomatosis  is   necessary   •  Understand  where  to  look  for  and  how  to   quanHfy  carcinomatosis   •  Know  the  protocol  of  CT  and  MR  examinaHons   for  evaluaHon  of  carcinomatosis   •  Know  the  role  and  added  value  of  involved   imaging  modaliHes  in  evaluaHon  of   carcinomatosis  
  • 3. General  consideraHons   •  Primary   – GI  :  colo-­‐rectal,  pancreaHc,  gastric   – Ovary/Breast   •  Outcome   – Median  survival:  7  months,  OS-­‐2  years  :    15%   – Limited  penetraHon  of  systemic   chemotherapy    
  • 4. •  New  agressive  treatment=  standard  [  for  paHents   with  disease  confined  to  peritoneum  and  CRC   –  Removal  of  macroscopical       –  HIPEC:  high  local  concentraHon  of    chemotherapy,  increased  in  drug  toxicity   with  heat,  for  microscopical   –  OS-­‐3  years:  53  %  and  OS-­‐5  years:  48.5  %   –  30  %  morbidity,  4  %  mortality   General  consideraHons  
  • 5. ROLE  OF  IMAGING   •  Not  only  Diagnosis  but   •  Extension  for  strategy  –  selecHon  of  paHents  for   surgery  +++,  even  if  perop  evaluaHon=  ref   –  PCI  =  peritoneal  cancer  index=>  score  0  to  39  (12  regions),     ex  Sugarbaker  score   •  Diameter  :  score  1  =  0-­‐5  mm,  score  2=  5  mm-­‐5  cm,  score   3  >  5  cm   –  Probability  to  obtain  R0  surgery    and    taken  into  account  as   CI  to  surgery  when  too  high  for  a  type  of  cancer   Sugarbaker PH, De Bree E., Jour Surg Oncol, 2004
  • 6. •  Extension  necessitaHng  expert  centre:   –  ResecHon  of  diaphragm  for  diaphragmaHc  nodule   –  HepaHc  parenchymal  invasion  from  implants,  Bowel   implants     –  Bladder  or  ureteral  invasion   •  Idea  of  length  and  morbidity   •  No  current  consensus  on  criteria  for  subopHmal   resecHon  but  some  lesions  suggest  non  resectability     ROLE  OF  IMAGING   Low AJR 2008 Low. Ann Surg Oncolo.2013 Nougaret.  Radiographics  2013  
  • 7.   Alert  surgeons  to  to  the  presence  of  disease  that  may  complicate  surgery  or  may   preclude  opHmal  debulking  .     Extensive  involvement  of  small  bowel-­‐  diffuse  mesenteric  infiltraHon  or  retracHon   of  the  root  of  mesentery    
  • 9. •  Bulky  hepatoduodenal-­‐  involved  node  sup  to  celiac  axis   •  Involvement  of  vesical  trigone  -­‐  pelvic  sidewall   Non  mucinous  CRC-­‐  not  resectable  because  involvement  of  duodenal  extension  
  • 10. •  IdenHfy  extraperitoneal  lesions   – Liver  small  or  central  mets  in  liver  ,  spleen  not  seen  with  lap   – Lymph  nodes   – Abdominal  wall   – Pleura   – Bone   Role  of  Imaging  
  • 11.   – Liver   – Lymph  nodes   – Abdominal  wall     – Pleura-­‐  inaccessible  with  lap   – Bone  
  • 12.       – Liver   – Lymph  nodes   – Abdominal  wall     – Pleura-­‐  inaccessible  with  lap   – Bone  
  • 13. Where  to  look  for  carcinosis?   – Gravity  dependent  areas  or  of  arrested  flows     •  Pelvic  recesses  (rectouterine,  lateral  paravesical,  RLQ),   Right  paracolic    gu[er  (phrenicocolic  lig  upward  on  the   lel),  ACE,  Morisson’s  recess,  Right  subdiaphragmaHc   space     •  RS  J,  Ileocaecal  juncHon,  pylorus   – Peritoneal  folds  containing  fat   •  Ligaments  :  reflexion  area  between  visceral  and  parietal    p       •  Mesos  :  mesentery,  transverse  meso  colon,  mesosigmoïd   •  Omentum       Nougaret  et  al.  RadioGraphics  2012.  32,  No.  6:  1775-­‐1800  
  • 14. PCI    SCORE-­‐Features         •   Involvement  of  parietal  serosa  :  peritoneal   thickening-­‐  nodules   •   Involvement  of  fa[y  areas  (omental  cake)     Nougaret  et  al.  RadioGraphics  2012  Vol.  32,  No.  6:  1775-­‐1800   plaques infiltration Reticulonodular lesions Mass (confluent nodules)
  • 15. •   Involvement  of  visceral  serosa     – Extrinsic  tumoral  infiltraHon  (ileocaecal,  right   colonic  angle,  RSJ)   – Distorsion  SB    (retracHon  of  mesentery)-­‐   Thickening   – ObstrucHon  
  • 17.   Adhesions=  deviaHon  of  a  structure  to  another  or  thickening  between   two  structures  without  fat  interface.      
  • 18.   nodules  of  the  mesentery  if  >7mm,  and/if  irregular  hypodense  nodules   and/if  numerous  :  grouped  and  >  8  on  one  slice        
  • 19. Other  signs   •  Ureteral  dilataHon   without  any  obstacle     •  Cardiophrenic  lymph   node     – 550  pts  with  CRC   – 30  %  proven  PC   – VPN  85  %/VPP  49  %     Caramella.  Eur  J  Cancer  2013   Two years after surgery for CRC. Ureteral dilatation due to carcinomatosis
  • 20. Pseudomyxoma   •  Intraperitoneal  seeding  of  mucin  secreHng  cells  responsible  for  mucin  in   the  peritoneum   –  Low  grade  and  high  grade  according  to  OMS  2010   –  From  mucinous  appendicular,  ovary     •  Features:   –  Diffuse  involvement     –  Thick  asciHs  with  scalloping  or  septas   –  Possibility  of  calcificaHons   –  Rarely    nodules  and  masses,  associated  organ  involvement  or  extent  to   pleura  
  • 21. ROLE  of  CT   •  Reference  imaging  for  staging  and  restaging  of  paHents:        >90  %  /paHent   •  Easily  available,  quick,  large  FOV       –  SpaHal  resoluHon  (1  mm  thick  slices)  and  3D  reformats:  reconstrucHon   using  3  mm  slices-­‐   –  Anayze  coronal  reformats  :  Nodule  in  at  least  two  planes  increases  confidence  in   diagnosis   •  Protocol:  IV  +±1  l  water      IV-­‐  for  ovary  and  CRC  (30  %  with  calcificaHons)     Chandrashekhara.  BJR.2011   Mazzei  2013.  Abdominal  imaging  
  • 22.         •  PCI:  underscores  staging   compared  with  surgery   •  Depends  on  size   – Se  <  15%  for  T<  0.5  cm   (miliary  in  liniHs)   – Se  <  25%  for  T  <  1  cm       – Se  around  40%  for  T  =  0.5  -­‐  5   cm   – Se  60  to  94%  for  T  >  5  cm        De  Bree.  JSO  2004                                                                                    Koh  Ann.  Surg  Oncol  .2009             Esquivel.  JSO  2010                                                                                Sala.  Radiology.  2010     ROLE  OF  CT-­‐  Limits   small lesion on mesentery plaque like lesion
  • 23. ROLE  OF  CT-­‐  Limits   •  Depends  on  site       –   Se<  20%  for  small  bowel  and  mesentery     –  Se  poor  for  diaphragmaHc  lesions   –  Se  variable  for  pelvis   •  Depends  on  level  of  experience   •  Depends  on  type  of    lesion  :  nodule  (k=0.8)/   thickening  (k=0.4)/distorsion  (k=0.2)   •  Depends  on    amount  of  fat     De  Bree.  JSO.  2004  
  • 24. ROLE  OF  CT-­‐  Limits   •   CharacterizaHon  of  nodules  and  of  asciHs  
  • 25. Role  of  CT-­‐Limits   Limits=  specificity  
  • 26. ROLE  OF  MRI   •  Few  studies  available,  parHcularly  in  paHents  without   neoadjuvant  treatment   •  MRI  versus  CT   –  Qayyum.  Gynecol  oncol  2005:  137  pts,  CT  =  MRI     –  Torkzad.  JSO  2015:  39  pts,  PCI  radio  CT  =  MRI,  EXCEPT  junior   –  Low.  Ann  surg  oncol.  2015:  22  pts:  Acc  =  85  vs  63%   •  MRI  versus  PET   –  Soussan.  Eur  radiol  2012:  30  pts  (13/33  (43%  opérés)                                            Ac  =  83  vs  80%  per  p[                                            per  site  MRI  +  per  lesion   –  Klumpp.  abdo  imaging  2012:  15  pts:  88  vs  94%.  MRI  without  diffusion       •  MRI  alone  –  pseudomyxoma   –  Low.  Ann  Surg  Oncol  2012:  33  p[s  (25  PMP)    Acc  0.84  
  • 27. MR  PROTOCOL   •  Fast/PEG  500  cc?     •  AnHperistalHc   agents   before   gadolinium   injecHon   =   glucagon   •  MRI  of  abdomen  and  pelvis  -­‐  2  stacks  to  cover  the   whole  peritoneal  cavity     – Axial  T2  single  shot  FSE  (trigger  free  breathing,  not   as  good  with  echo  nav),  5-­‐6  mm,  sans  Fatsat   – Axial  Diffusion  (b  0-­‐800)     – Axial  post  gadolinium-­‐enhanced  T1-­‐weighted  art/ portal/late  phase  (5  minutes).    
  • 28. T2  :    Added  value  for  PCI  assessment   •   limited  added  value  in  non  mucinous  lesions  
  • 29. T2  :    Added  value  for  PCI   assessment   •   added  value  ++  for  mucinous  lesions  
  • 30. Gadolinium:  Added  value  for  PCI  assessment   •  non  mucinous  lesions-­‐  peritoneal  thickening  
  • 31. Gadolinium: Added value for PCI assessment  
  • 32.   Gadolinium:  Added  value  for  PCI   assessment     Mucinous lesions
  • 33. Tissu sain Tissu tumoral  Diffusion:  Added  value  for  PCI   assessment-­‐Contrast  resoluHon-­‐ detecHon  
  • 34. Diffusion:  Added  value  for  PCI   assessment-­‐DetecHon     Diffusion:  non  mucinous  lesions-­‐  added  value   parHcularly  for  difficult  areas  with  CT   Low  -­‐  AJR  2009  :    255  sites  lésionnels   n  Standard  MRI  se  73  -­‐  52%,  sp  92%  (k  =  0,67)   n  Diffusion  b  =  500  se  71  -­‐  71%,  sp  90%  (k  =  0,67)   n  MR  conv.  +  Diff      se  90  -­‐  84%,  sp  91%  (k  =  0,77)    
  • 37. Small  bowel  serosa      <  5  mm   Added  value  for  pelvis    and  small  bowel   WARN  SURGEON  =>  morbidity  
  • 38.   Abdominal  wall  lesion    <  10  mm   Added  value  for  special  sites    such  as  abdominal  wall  
  • 39. Diffusion:  Added  value  for  PCI   assessment-­‐CharacterizaHon  
  • 40. Diffusion-­‐Limits   •  Limits  of  diffusion  sequences   –  T2  shine  through  effect=>  ADC   –  RestricHon  of  diffusion  from  less  cellular  some  lesion:   mucin,  adhesions,  confluent  areas,  fibrosis   –  Lesions  with  blood,  mucoid  content  
  • 41. MR  Technique-­‐Limits   •  PaHent-­‐dependent   •  PeristalHsm   •  Black  hole  effect-­‐  get  rid  of  the  asciHs  before   MRI   •  ParHal  volume  effect-­‐spaHal  resoluHon   •  Interobserver  Variability  (per  site)-­‐  learning   curve      
  • 42. PET  CT-­‐  Main  IndicaHons   •  Strong  Clinical  suspicion  of  PC  or  increase  in  markers   level  with  normal  CT   •  DetecHon  of  recurrence  versus  fibrosis     •  Assessment  before  HIPEC     –  Underscores  PCI  but  complementary  to  CT/MRI     –  Rules  out  extraperitoneal  lesions  contraindicaHng  surgery    
  • 43. –  False  negaHve   •  Mucinous  tumors,  low  grade  pseudomyxoma  and    gastric  liniHs       PET  CT-­‐  Limits   Passot.Eur  J  Surg  Oncol.  2010                        Anthony.  AJR.2009                                Hymnimen.  Gynecol  oncol.  2013  
  • 44. PET  CT-­‐  Limits   •  False  negaHve   –  Size  <  1cm   –  Hidden  lesions  by  respiratory  and  GI  movements   •  False  posiHve:  specificity  <  CT   –  Inflammatory  reacHon  of  peritoneum  around  large  or  numerous  implants     –  Foreign  body  or  inflammatory  reacHon  related  to  previous  surgery     –  Physiological  uptake  of  bowel  and  vessels         Pierandrea  de  Iaco.  EJR.  2011  
  • 45. Conclusion   –  CT=  reference  imaging       –  Before    deciding  upon  treatment   MRI  ±PET  scanner  needed     •  For  assessment  of  PCI   •  Detect  lesions  needing  expert   center   •  Detect  non  resectable  disease   –  Added  value  of  diffusion  for  small   bowel,  pelvis  ,  hepaHc  hilum,   pseudomyxoma  ++   –  PET/CT  for  extraperitoneal  disease   –  COMBINE  modaliHes