Communicating imaging findings in peritoneal mesothelioma: the impact of \u2018PAUSE\u2019 on surgical decision-making

Anuradha Chandramohan,Andrew Thrower,Nehal Shah,Rohin Mittal,Norman John Carr,Brendan Moran,Faheez Mohamed

doi:10.1186/s13244-021-01118-y

Abstract

The peritoneal cavity is the second commonest site of mesothelioma after the pleural cavity. There are five histological types of peritoneal mesothelioma with variable symptomatology, clinical presentation and prognosis. Cystic mesothelioma is a borderline malignant neoplasm with a favourable prognosis, well-differentiated papillary mesothelioma is generally a low-grade malignancy, and all other varieties such as epithelioid, sarcomatoid and biphasic mesothelioma are highly malignant types of peritoneal mesothelioma with poor prognosis. Malignant peritoneal mesothelioma was considered inevitably fatal prior to the introduction of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in selected cases where long-term survival and cure could be achieved. However, the survival benefits following CRS and HIPEC mainly depend on completeness of cytoreduction, which come at the cost of high morbidity and potential mortality. Using the acronym ‘PAUSE’, we aimed at describing the key imaging findings that impact surgical decision-making in patients with peritoneal mesothelioma. PAUSE stands for peritoneal cancer index, ascites and abdominal wall disease, unfavourable sites of involvement, small bowel and mesenteric disease and extraperitoneal disease. Reporting components of ‘PAUSE’ is crucial for patient selection. Despite limitations of CT in accurately depicting the volume of disease, describing findings in terms of PAUSE plays an important role in excluding patients who might not benefit from CRS and HIPEC.

Highlights

Imaging findings that impacts surgical decision making in peritoneal mesothelioma can be communicatedeffectively using the acronym PAUSE, which stands for Peritoneal Cancer Index, Ascites and abdominal wall disease, Unfavourable sites, Small bowel and mesenteric disease and Extraperitoneal disease
CT is a good technique for identifying patients with high peritoneal cancer index (PCI) disease, who may not benefit from cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC)
Peritoneal mesothelioma is a rare condition arising from the mesothelial cells lining the peritoneal cavity

Summary

Key Points

Imaging findings that impacts surgical decision making in peritoneal mesothelioma can be communicatedeffectively using the acronym PAUSE, which stands for Peritoneal Cancer Index, Ascites and abdominal wall disease, Unfavourable sites, Small bowel and mesenteric disease and Extraperitoneal disease. CT is the initial modality of choice for evaluating patients with peritoneal mesothelioma. CT is a good technique for identifying patients with high PCI disease, who may not benefit from CRS and HIPEC

Introduction

Findings

Conclusions