The subpyloric space

Courtesy of PH Sugarbaker, MD

The superior recess of the omental bursa

Tac criado cuervo

The superior recess of the omental bursa

Tac criado cuervo

The superior recess of the omental bursa

The small bowel

The small bowel mesentery

The small bowel

PET/CT scan in peritoneal carcinomatosis

PET/CT scan in peritoneal carcinomatosisPatient selection in GI peritoneal carcinomatosis

PET/CT scan in peritoneal carcinomatosisPatient selection in GI peritoneal carcinomatosis

PET/CT scan in peritoneal carcinomatosisPatient selection in GI peritoneal carcinomatosis

PET/CT scan in peritoneal carcinomatosisPatient selection in GI peritoneal carcinomatosis

Prospective evaluation / N=30

Dromain C et al. Staging of peritoneal carcinomatosis: enhanced CT vs. PET/CT. Abdom Imaging 2008; 33:87-93

80 %

0

57 %

PET/CT

70 %Understimationof diseaseextent

83 %26 %Small bowelimplants

82 %Sensitivity

10.25.4Mean PCI

SurgeryCT

PET/CT scan in peritoneal carcinomatosisPatient selection in GI peritoneal carcinomatosis

Prospective evaluation / N=30

Dromain C et al. Staging of peritoneal carcinomatosis: enhanced CT vs. PET/CT. Abdom Imaging 2008; 33:87-93

80 %

0

57 %

PET/CT

70 %Understimationof diseaseextent

83 %26 %Small bowelimplants

82 %Sensitivity

10.25.4Mean PCI

SurgeryCT

PET/CT scan in peritoneal carcinomatosisPatient selection in GI peritoneal carcinomatosis

Prospective evaluation / N=30

Dromain C et al. Staging of peritoneal carcinomatosis: enhanced CT vs. PET/CT. Abdom Imaging 2008; 33:87-93

CT PET/CT

SURGERY

Mucinous > Non-mucinous Mucinous = Non-mucinous

Moderate (0.53) Low

(0.1

2)

Interclass Correlation

MRI in peritoneal carcinomatosis

Low, RS. Magnetic Resonance Imaging in the Oncology Patient: Evaluation of the extrahepaticabdomen. Semin Ultrasound CT MRI 2005; 26:224-36

- Outstanding soft tissue contrast

- Fat-supressed, gadolinium-enhanced SGE MRI

- Use of intraluminal contrast (diluted barium, metamucil and water)

- Ability to detect subtle peritoneal disease

CT vs. MRI in peritoneal carcinomatosis

SuperiorAverageAssessment of softtissue

YesNoMovement artifacts

Less

Yes

Longer

Lower

MRI

MoreFamiliarity forclinicians / availability

YesMultiplanar imaging

ShortAcquisition time

SuperiorSpatial resolution

CT

MRI in peritoneal carcinomatosis

Low, RS. Magnetic Resonance Imaging in the Oncology Patient: Evaluation of the extrahepaticabdomen. Semin Ultrasound CT MRI 2005; 26:224-36

CT vs. MRI in peritoneal carcinomatosis

Low, RS. Extrahepatic Abdominal Imaging in Patients With Malignancy: Comparison of MR Imagingand Helical CT in 164 Patients. J. Magn. Reson. Imaging 2000;12: 269–277.

MRI in peritoneal carcinomatosis

Low, RS. Extrahepatic Abdominal Imaging in Patients With Malignancy: Comparison of MR Imaging and Helical CT in 164 Patients. J. Magn. Reson. Imaging 2000;12: 269–277.

MR imaging was equivalent to single-phase helical CT fordepicting extrahepatic tumor at most anatomic sites andshowed an advantage for depicting tumor involving theperitoneum, intestinal tract, bones and vascular structures

16,13 %15,63 %

70,97 %81,25 %

12,90 %3,13 %

3. Magnetic resonance imaging

16,13 %9,38 %

64,52 %84,38 %

19,35 %6,25 %

2. PET total body

0 %0 %

3,23 %0 %

96,77 %100,00 %

1. Thin slice CT scan (with adequate intravenous, oral, +/-rectal contrast media)

USELESSUSEFUL,

NOT FUNDAMENTALFUNDAMENTALExam

Yan TD et al. J Surg Oncol 2008; 98:224-7

“…no radiologic test is reliable for the detection of small volume of cancer that is layered out on a peritoneal surface”

Diagnostic imaging of peritoneal carcinomatosis

Sugarbaker PH. Buillding on a consensus. J Surg Oncol 2008; 98:215-6

“…no radiologic test is reliable for the detection of small volume of cancer that is layered out on a peritoneal surface”

Diagnostic imaging of peritoneal carcinomatosis

Sugarbaker PH. Buillding on a consensus. J Surg Oncol 2008; 98:215-6

Conclusions1. Enhanced CT of the thorax, abdomen and pelvis (oral, iv, rectal) is the current imaging standard to evaluate peritoneal surface malignancy patients for surgical exploration with the intent to perform complete cytoreductive surgery and HIPEC

2. We can expect:

- A good sensitivity for the detection of peritoneal carcinomatosis but an understimation of peritoneal disease extent

- Reasonable detection of extraperitoneal disease (complemented by PET/CT)

- Identification of key features that preclude a complete cytoreduction

- Help in planning surgical procedure

Conclusions

3. Gadolimiun-enhanced, fat-supressed MRI is a good imaging complement to CT scan for the detection of subtle peritoneal, mesenteric or bowel surface disease, but its actual clinical integration in peritoneal surface malignancy practices is yet to occur

4. The role of PET /CT is limited to the detection of extraperitoneal disease. Its role in the evaluation of peritoneal disease extent is marginal.

Imaging in peritoneal carcinomatosis

“Radiological evaluation of peritoneal surface malignancy”

PI: Luis Rodriguez-Bachiller, MD

AI: Luis González-Bayón, MD, PhD et al.

Prospective comparative evaluation of CT, MRI, PET/CT against surgical findings (target n=99)

Determine the most adequate combination ofimaging tests to select patients for CRS + PIC

Peritoneal Surface Oncology Program

Anesthesiology

Radiology Pathology

Intensive Care O.R. Nursing

NursingEducation

HospitalizationNursing

Medical Oncology

PalliativeCare

Surgical Oncology

ClinicalNutrition