Diagnosis Of Peritoneal Carcinomatosis Research Articles

Endoscopic ultrasonography can avoid unnecessary laparotomies in patients with pancreatic adenocarcinoma and undetected peritoneal carcinomatosis

Background/ObjectiveTo assess the relationship between the presence of ascites detected by endoscopic ultrasonography (EUS) and peritoneal carcinomatosis (PC) in patients with pancreatic adenocarcinoma. MethodsConsecutive patients who underwent a EUS for preoperative staging of a pancreatic adenocarcinoma between 1998 and 2014 were retrospectively reviewed. The diagnosis of PC was confirmed by histopathology or peritoneal fluid cytology. The main outcome of the study was the relationship of ascites at EUS and PC in patients with pancreatic cancer. Secondarily, to evaluate the relationship between this finding and survival as well as the development of PC during follow-up. ResultsA total of 136 patients were included: 30 patients with local unresectable tumor or metastatic disease and 106 potentially-resectable candidates based on CT staging. EUS showed ascites in 27 (20%) patients, of whom 8 (29.6%) had PC. The sensitivity, specificity, PPV, NPV and accuracy of ascites by EUS in the detection of PC in this group of patients were 67%, 85%, 30%, 96% and 83%, respectively. Ascites detected by EUS was the only independent predictive factor of PC with an OR of 11 (CI 95%: 3–40). The detection of ascites by EUS was associated with a shorter survival (median survival time 7,3 months; range 0–60 vs 14.2 months; range 0–140) (p = 0.018) and earlier development of PC during follow-up (median 3.2 months, range 1.4–18.1 vs 12.7 months, range 5.4–54.8; p = 0.003). ConclusionThe finding of ascites at EUS in patients with pancreatic adenocarcinoma is highly associated with PC and a poor outcome.

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy for peritoneal malignancy: preliminary results of a multi-disciplinary teamwork model in Asia

Background: Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) is an emerging surgical procedure for peritoneal carcinomatosis (PC). CRS/HIPEC is a complicated treatment that requires multi-disciplinary teamwork (MDT), which may be lacking when establishing a CRS/HIPEC programme. Herein, we report our preliminary treatment outcomes with the early implementation of an MDT model for CRS/HIPEC.Methods: From April 2015 to December 2016, 45 patients with a diagnosis of PC who received CRS/HIPEC were reviewed retrospectively in a single institution in Taiwan.Results: Among the 45 patients, CRS was mainly performed by laparotomy (n = 42), and only three patients with limited PC underwent laparoscopic CRS. The first 13 patients received treatment before the MDT had been established (group 1), and the other 32 patients were treated after the MDT had been established (group 2). The highest peri-HIPEC body temperature in group 2 was significantly lower than that in group 1 (36.8 °C vs. 37.5 °C, p < 0.001). Overall, eight patients experienced major complications. The trend of a lower major complication rate was observed after the MDT model had been implemented (30.7% in group 1 vs. 12.4% in group 2, p = 0.202). Pre-CRS/HIPEC abdominal pain significantly increased the risk of post-operative major complications (p = 0.017).Conclusions: Our experience suggests that the early implementation of an MDT model when establishing a CRS/HIPEC programme at a single institution may result in a higher complete cytoreduction rate and lower major complication rate, and also shorten the learning curve of this complicated procedure.

Role of laparoscopy in the Etiologic Diagnosis of Ascites of Unknown Origin

Introduction: Ascites is a consequence of many different etiologies, such as liver cirrhosis, neoplasm, tuberculous peritonitis, pyogenic peritonitis, congestive heart failure, renal and pancreatic diseases but, in some situations, ascites is of unknown cause in spite of comprehensive study. The aim of this study was to identify the role of laparoscopy in the etiological diagnosis of ascites of unknown origin.Methods: This was a prospective study of the patients who underwent diagnostic laparoscopy to determine the causes of ascites of unknown origin in the Department of Surgery, Nepalgunj Medical College Teaching Hospital from April 2012 to May 2014. All the patients underwent laparoscopy for the evaluation of ascites after appropriate clinical and laboratory examinations, which failed to reveal the cause.Results: Peritoneal tuberculosis and carcinomatosis peritonei were the two most common causes found in 37.14% and 57.14% of cases respectively. The average age of the patients was 52 years. Distension of abdomen, abdominal pain and weight loss were the most frequently observed symptoms in 33 patients (100%), 26 patients (74.28%) and 18 patients (51.42%) respectively. The CT scan findings, were a omental thickening in 28 cases (80%), peritoneal nodules in 7(20%) patients and the intraabdominal lymph nodes in 13 patients (39.39%). Ovarian mass was found in 4 patients (11.42%). The histological diagnosis was a peritoneal carcinomatosis in 13 (37.14%) patients and peritoneal tuberculosis in 20 (57.1%) patients and in two patients nonspecific inflammation. The sensitivity and specificity of laparoscopic diagnosis in the diagnosis of peritoneal tuberculosis were 78.67% and 98.6% respectively and in the diagnosis of peritoneal carcinomatosis were 94.78% and 72.2% respectively. The positive predictive value was 97.3% and the negative predictive value was 73.7% for peritoneal tuberculosis and for peritoneal carcinomatosis the positive predictive value was 83.7% and negative predictive value was 94.87%.Conclusion: The etiologic diagnosis of ascites of unknown origin is difficult despite the availability of several tests. Laparoscopy with peritoneal biopsy has still got a role in diagnosing these types of ascites where the other laboratory and imaging studies fail to reveal the cause.Journal of Nepalgunj Medical College Vol.13(1) 2015: 13-16

A feasibility study of the use of computed virtual chromoendoscopy for laparoscopic evaluation of peritoneal metastases.

Detection of an incipient peritoneal carcinomatosis (PC) is still challenging, and there is a crucial need for technological improvements in order to diagnose and to treat early this condition. Fujinon Intelligent Chromo Endoscopy (FICE) is a spectral image processing technology that enhances the contrast of the target tissue. The aim of this study is to investigate the usefulness of FICE system during peritoneal endoscopy and to establish the optimal FICE preset(s) for peritoneal exploration and PC detection. A total of 561 images corresponding to 51 different areas of PC nodules and normal peritoneum were recorded during peritoneal endoscopies (For each area, one white light endoscopy (WLE) image and 10 FICE images). Three groups of 5 evaluators each: senior surgeons, surgical residents and medical students assessed these images. In a first questionnaire, the evaluators gave a score ranging from 1 to 10 to each image, and the three best FICE channels were determined. In a second questionnaire, five criteria were studied specifically: contrast, brightness, vascular architecture, differentiation between organs and detection of PC. The evaluators ranked the WLE and the three best FICE channel images according to these criteria. The three best FICE channels were channels 6, 2 and 9 with mean scores of 6.21±1.59, 6.17±1.48 and 6.06±1.52, respectively. FICE Channel 2 was superior to WLE and other FICE channels, in terms of contrast (p<10-4), visualization of vascular architecture (p<10-4), differentiation between organs (p<10-4) and detection of PC (p<10-4); and ranked first in 38.8, 41.5, 31 and 46.9% of the cases, respectively. FICE system provides adequate illumination of the abdominal cavity and a unique contrast that enhances the vascular architecture. FICE Channel 2 is the optimal channel for peritoneal exploration and could be a useful tool for the diagnosis of PC during peritoneal explorations.

Cardiophrenic angle lymph node is an indicator of metastatic spread but not specifically peritoneal carcinomatosis in colorectal cancer patients: Results of a prospective validation study in 91 patients

BackgroundThe presence of cardiophrenic angle lymph node (CPALN) has been associated with the risk of peritoneal carcinomatosis (PC) in high risk colon cancer patients. Its accuracy to predict PC and its prognostic value in non-selected CRC patients has not been validated prospectively. MethodsFrom 2011 to 2013, all patients undergoing colectomy for colon cancer were included prospectively. Presence of CPALN was assessed on preoperative computed tomography scan by two radiologists. Surgical exploration was used as reference for the diagnosis of PC. Factors associated with presence of CPALN and progression-free survival were analyzed. ResultsNinety one patients fulfilled inclusion criteria. CPALN was detected in 36 patients (39.5%) on CT scan. At surgical exploration, PC was found in 6 patients (6.5%). Sensitivity, specificity, negative predictive value, positive predictive value and overall accuracy of CPALN on CT scan for predicting PC were 67%, 62%, 96%, 11% and 63% respectively. In multivariate analysis, the presence of distant metastases whatever the site was associated with the presence of CPALN (p = 0.03; hazard ratio HR = 3.8; confidence interval CI 95% = 1.1–13.3). In the multivariate analysis, only vascular involvement (p = 0.034, HR = 3.574, CI 95% = 1.10–11.60) was associated with progression-free survival whereas CPALN was not found to predict outcome (p = 0.893). ConclusionCPALN is a common finding in non-selected colon cancer patients. Although in the absence of CPALN, PC can almost be excluded, its value for the diagnosis of PC is limited. Our findings support that CPALN is mainly an indicator of metastatic spread of the tumor.

Pseudomyxoma Peritonei from a Borderline Mucinous Tumor Arising in an Ovarian Mature Cystic Teratoma: A Rare Case Report

Pseudomyxoma peritonei (PMP) is a rare associated diagnosis of peritoneal carcinomatosis which, classically, has been characterized by a slowly progressive disease process. More recently, Ronnett et al., have histologically classified PMP into the slow growing disseminated peritoneal adenomucinosis (DPAM), the much more aggressive and invasive peritoneal mucinous carcinomatosis (PMCA) and an intermediate group (ID). Recent studies have shown that most cases of PMP arise from ruptured appendiceal tumors with dissemination of mucin producing epithelial cells into the peritoneal cavity. PMP, contrary to popular belief, almost never arises from a ruptured primary ovarian mucinous tumor, corroborated by two of the largest series on ruptured borderline mucinous ovarian neoplasms. A small number of cases have been reported, however, with peritoneal carcinomatosis secondary to rupture of an ovarian mucinous tumor associated with a mature cystic teratoma. These are usually CK7 negative and CK20 positive, and are immunohistochemically consistent with intestinal type of mucinous tumors that arise from intestinal elements of the teratoma. Other malignancies such as squamous cell carcinomas, malignant endodermal sinus tumors and chorio-carcinomas have been shown to arise from a mature teratoma. We present a case report describing one such rare case of DPAM arising from a ruptured borderline mucinous ovarian tumor in the background of a cystic teratoma.

Single-incision flexible endoscopy (SIFE) for detection and staging of peritoneal carcinomatosis.

To show the feasibility and the safety of peritoneal carcinomatosis (PC) evaluation by single-incision flexible endoscopy (SIFE) and to compare it to single-incision rigid endoscopy (SIRE). Direct peritoneal visualization, either by laparotomy or laparoscopy, continues to be the gold standard in diagnosing PC. We reported, in animal study, that combining single-incision laparoscopic surgery and flexible endoscopy improved evaluation of the peritoneal cavity in a live porcine model and in four human cadavers. Patients, undergoing surgical exploration for diagnosis and staging of PC, were included in a prospective study. Using a superiority design a sample size of 47 patients was determined. Through a single incision, a standardized peritoneoscopy was conducted with rigid (SIRE) and with flexible endoscope (SIFE). Primary outcome was the access success rates for the 13 regions of the Peritoneal Carcinomatosis Index (PCI). Overall access to the 13 regions of PCI was successful in 83% of the cases with SIRE and in 91.1% with SIFE (p<10(-10)). SIFE access rates were superior to SIREs' in the regions: R1 (87.2 vs. 61.7%, p=0.002), R2 (87.2 vs. 66%, p=0.004), R3 (85.1 vs. 59.6%, p=0.001) and R6 (80.9 vs. 61.7%, p=0.008). The mean PCI was higher (p<10(4)) with SIFE 12.77 (±11.97) than with SIRE 11.77 (±11.63). This prospective, comparative study shows that SIFE was significantly superior to SIRE in the exploration of some difficult-to-access peritoneal areas, located in regions 1, 2, 3 and 6. These two minimally invasive staging procedures are safe, feasible and have to be seen as complementary rather than competing.

The presence of cardiophrenic angle lymph nodes is not an indicator of peritoneal carcinomatosis from colorectal cancer on MDCT: Results of a case-control study

ObjectiveTo determine if the presence of cardiophrenic angle lymph nodes (CPALNs) on multidetector-row computed tomography (MDCT) can be considered as an indicator of peritoneal carcinomatosis (PC) in patients with colorectal cancer (CRC). Material and methodsTwo groups of 101 patients each were retrospectively included. Group 1 included patients with PC from CRC and Group 2 included patients with CRC without PC. MDCT examinations were analyzed by two readers working in consensus for the presence or absence of CPALNs and, when present for their dimensions (short and long axis), location (right, left or bilateral) and shape (oval or rounded). ResultsPrevalence of CPALNs was 29% in Group 1 and 32% in Group 2. No differences in prevalence of CPALNs were found between the two groups (P = 0.458). Presence of CPALNs had a sensitivity of 29% (95%CI: 23–35%) for the diagnosis of PC and a specificity of 68% (95%CI = 62–74%). No differences in CPALN dimensions, location and shape were found between these two groups. ConclusionPresence of CPALNs cannot be considered as an indicator of PC in patients with CRC. In addition, when present, CPALNs have similar dimensions, location and shapes in patients with PC from CRC than in those without PC.

A Case of Pseudomyxoma Peritonei in a 69 Years Old Woman and Review of Literature

Pseudomyxoma peritonei (PMP) is a rare neoplasm characterized by the production of abundant mucin or gelatinous ascites with involvement of the peritoneal surface and omentum. Usually it is associated with benign or malignant mucinous tumor of the appendix or ovary but there are also cases described with other side as colon, rectum, stomach, gallbladder, biliary tract and so on The overall incidence is 1-2 per million per year, it is more common in women than in men (male: female ratio: 9:11). Signs and Symptoms of PMP are very a specific for this reason this disease is often discovered incidentally during other surgical procedure or diagnostic procedure of other pathology. Treatment ranges from debulking to hyperthermic intraperitoneal chemotherapy (HIPEC) with cytoreductive surgery (CRS). In this article we want to describe a case of PMP discovered during a diagnostic laparoscopy in a 69 years old woman with a specific symptoms and a diagnosis of peritoneal carcinomatosis at CT SCAN and to review the literature about this rare pathology.

Cytoreduction and HIPEC in the treatment of "unconventional" secondary peritoneal carcinomatosis.

BackgroundPeritoneal metastasis (PM) is considered a terminal and incurable disease. In the last 30 years, cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) radically changed the therapeutic approach for these patients and is regarded as the standard of care for pseudomyxoma peritonei from appendiceal cancer and peritoneal mesotheliomas. Improved survival has also been reported in treating PM from ovarian, gastric, and colorectal cancers.However, PM often seriously complicates the clinical course of patients with other primary digestive and non-digestive cancers. There is increasing literature evidence that helped to identify not only the primary tumors for which CRS and HIPEC showed a survival advantage but also the patients who may benefit form this treatment modality for the potential lethal complications.Our goal is to report our experience with cytoreduction and HIPEC in patients with PM from rare or unusual primary tumors, discussing possible “unconventional” indications, outcome, and the peculiar issues related to each tumor.MethodsFrom a series of 253 consecutive patients with a diagnosis of peritoneal carcinomatosis and treated by CRS and HIPEC, we selected only those with secondary peritoneal carcinomatosis from rare or unusual primary tumors, excluding pseudomyxoma peritonei, peritoneal mesotheliomas, ovarian, gastric, and colorectal cancers. Complications and adverse effects were graded from 0 to 5 according to the WHO Common Toxicity Criteria for Adverse Events (CTCAE). Survival was expressed as mean and median.ResultsWe admitted and treated by CRS and HIPEC 28 patients with secondary peritoneal carcinomatosis from rare or unusual primary tumors. Morbidity and mortality rates were in line with those reported for similar procedures. Median survival for the study group was 56 months, and 5-year overall survival reached 40.3 %, with a difference between patients with no (CC0) and minimal (CC1) residual disease (52.3 vs. 25.7), not reaching statistical significance. Ten patients are alive disease-free, and eight are alive with disease.ConclusionsCytoreduction and HIPEC should not be excluded “a priori” for the treatment of peritoneal metastases from unconventional primary tumors. This combined therapeutic approach, performed in an experienced center, is safe and can provide a survival benefit over conventional palliative treatments.

Looking up: Recent advances in understanding and treating peritoneal carcinomatosis.

Until recently, a diagnosis of peritoneal carcinomatosis was uniformly accompanied by a grim prognosis that was typically measured in weeks to months. Consequently, the management of carcinomatosis revolves largely around palliation of symptoms such as bowel obstruction, nausea, pain, fatigue, and cachexia. A prior lack of effective treatment options created the nihilistic view that currently exists and persists despite improvements in the efficacy of systemic therapy and the evolution of multimodality approaches including surgery and intraperitoneal chemotherapy. This article reviews the evolution and current state of treatment options for patients with peritoneal carcinomatosis. In addition, it highlights recent advances in understanding the molecular biology of carcinomatosis and the focus of current and future clinical trials. Finally, this article provides practical management options for the palliation of common complications of carcinomatosis. It is hoped that the reader will recognize that carcinomatosis is no longer an imminent death sentence and that through continued research and therapeutic innovation, clinicians can make an even greater impact on this form of metastatic cancer.

Routine second-look after surgical treatment of colonic peritoneal carcinomatosis

Surgical procedures that combine both complete cytoreductive surgery (CCRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) have improved the survival of patients with peritoneal carcinomatosis (PC). Current imaging and laboratory investigations are not very useful to diagnose PC. This prospective study sought to determine the usefulness of routine second-look surgery (RSLS) combined with HIPEC in the diagnosis and treatment of patients with PC at high-risk for recurrence. From 2007 to 2011, RSLS was performed on 14 patients who had undergone a complete initial oncological resection for synchronous colonic PC and/or ovarian metastasis with PC discovered during primary colon cancer surgery after a course of 12 cycles of intravenous chemotherapy, eventually associated with HIPEC. Pathology confirmed PC in 71% of patients during RSLS, with a median peritoneal carcinomatosis index (PCI) of 10. There was no post-operative mortality, while 7% of patients exhibited Dindo Grade III-IV complications. The 2-year overall survival and disease-free survival rates were 91% and 38%, respectively. Following RSLS and CCRS, peritoneal recurrence was observed in only 8% of patients who had undergone HIPEC. RSLS combined with HIPEC after initial resection of synchronous colonic PC allows diagnosis and treatment of low-score PC, with limited post-operative complications and increased overall survival rates.

457. Attitude in the casual intraoperative diagnosis for peritoneal carcinomatosis from unknown origin

457. Attitude in the casual intraoperative diagnosis for peritoneal carcinomatosis from unknown origin

Metachronous peritoneal carcinomatosis after curative treatment of colorectal cancer

IntroductionPopulation-based data on metachronous peritoneal carcinomatosis (PC) after curative resection of colorectal origin are scarce. The aim of this study was to investigate the incidence of and risk factors for developing metachronous PC from colorectal cancer as well as survival since diagnosis of PC. MethodsData on metachronous metastases were collected between 2010 and 2011 for all patients diagnosed with M0 colorectal cancer between 2003 and 2008 in the Dutch Eindhoven Cancer Registry. Median follow-up was 5.0 years. Survival was defined as time from metastases diagnosis to death. ResultsOf the 5671 colorectal cancer patients, 1042 (18%) were diagnosed with metachronous metastases of whom 197 (19%) developed metachronous PC. The peritoneal surface was the only site of metastasis in 81 (41%) patients while 116 (59%) patients were diagnosed with both PC and metastases elsewhere. Median survival after diagnosis of PC was 6 months compared to 15 months for patients with distant metastases in other organs. Patients with an advanced primary tumour stage, positive lymph nodes at initial diagnosis, primary mucinous adenocarcinoma, positive resection margin and a primary tumour located in the colon were at increased risk of developing metachronous PC. ConclusionOf the colorectal cancer patients who developed metachronous metastases, approximately one fifth is diagnosed with PC. Prognosis of these patients is poor with a median survival of 6 months after diagnosis. Identifying patients at high risk for developing metachronous PC is important as it may contribute to more accurate patient information, tailor-made follow-up schemes, and more adequate treatment.

Value of cardiophrenic angle lymph node for the diagnosis of colorectal peritoneal carcinomatosis

BackgroundCardiophrenic angle lymph nodes (CPALN) have been reported in patients with abdominopelvic malignancies. We aimed to assess whether the presence of CPALN is associated with peritoneal carcinomatosis (PC) in colorectal cancer. Patients and methodsBetween 2007 and 2011, 550 patients with colorectal cancer, including 165 (30%) with PC, had undergone surgery with complete peritoneal exploration. We retrospectively reviewed preoperative CT scans for the presence of CPALN and assessed its association with confirmed PC by univariate and multivariate analyses. ResultsCPALN were present in 123 (75%) patients with PC, but absent in 263 (68%) patients without PC (Se: 0.72; Sp: 0.68; PPV: 0.49; NPV: 0.85; [OR], 3.3; p<0.001). PC was the only factor independently associated with CPALN in the multivariate analysis. CPALN was not correlated with the presence of liver metastases. 99 of the 165 patients with PC (62%) had visible signs of PC on CT scan. Among the remaining 66 patients, CPALN were the only potential sign of PC in 41 (62%), (Se 0.62, Sp 0.68, PPV 0.24, and NPV 0.92). ConclusionThe detection of CPALN on CT may be of valuable help for the diagnosis of PC in patients with CRC.

Value of cardiophrenic angle lymph nodes for the diagnosis of colorectal peritoneal carcinomatosis.

372 Background: The radiological diagnosis of peritoneal carcinomatosis (PC) is challenging. Metastases in the cardiophrenic angle lymph nodes (CPALN) have been anecdotally reported in patients with abdominopelvic malignancies. We aimed to assess whether CPALN detected by computed tomography (CT)-scan are associated with PC in patients with colorectal cancer (CRC). Methods: Between 2007 and 2010, 550 patients with CRC, including 165 (30%) with PC, underwent surgery with complete exploration of the peritoneal cavity in our center. We retrospectively reviewed preoperative CT-scans for the presence of CPALN, and assessed the association of CPALN with surgically confirmed PC by univariate and multivariate analyses. Results: CPALN were present in 123 (75%) of the 165 patients with PC, but absent in 263 (68%) of the 385 patients without PC (sensitivity (Se), 0.72; specificity (Sp), 0.68; positive predictive value (PPV), 0.49; negative PV (NPV), 0.85; odds ratio [OR], 3.3; p&lt;0.001). The presence of CPALN was not correlated with the extent of PC, the primary tumor and lymph node status , or the presence, number, size and location of liver metastases. Among the 165 patients with PC, 99 (60%) had visible signs of PC (other than CPALN) on CT-scan; among the remaining 66 patients, CPALN were the only potential sign of CP in 41 (62%), leading to Se, Sp, PPV, and NPV in patients with no signs of CP (other than CPALN) on CT of 0.62, 0.68, 0.24, and 0.92, respectively. Conclusions: The detection of CPALN on CT may be of valuable help for the diagnosis of PC in patients with CRC.

Update on Colorectal Carcinomatosis—From Molecular Biology to Diagnosis and Management

After liver metastases, Peritoneal Carcinomatosis (PC) is the second most frequent cause of death in patients with Colorectal Cancer (CRC), although the precise incidence of Colorectal Cancer Peritoneal Carcinomatosis is not known, as the majority of the diagnostic studies cannot detect the disease in its initial stages, nowadays, the diagnosis of peritoneal carcinomatosis remains a challenge. The molecular biology of PC is only just beginning to be understood, future knowledge will permit not only identify novel strategies for PC prevention, but also contribute to therapeutic advances, through the development of molecular targeted therapies. The authors performed a literature revision about the Molecular Biology, Diagnosis and Management of Colorectal Cancer Peritoneal carcinomatosis.

Usefulness of Dual-Time Point Imaging After Carbonated Water for the Fluorodeoxyglucose Positron Emission Imaging of Peritoneal Carcinomatosis in Colon Cancer

Fluorodeoxygluose (FDG) positron emission/computed tomography (PET/CT) is emerging as a useful tool for the diagnosis of peritoneal carcinomatosis (PC). In this study, we assessed whether dual-time point imaging can improve the accuracy of FDG PET/CT for the diagnosis of PC after colon rectal cancer (CRC). Thirty-nine patients with past history of CRC were evaluated. Whole-Body PET/CT scan was acquired 1 hour after tracer injection. If one or more focal areas of increased FDG uptake (standardized uptake value, SUV max>2.5) were found in the abdomen, 1 L of carbonated water was orally administered to patients and a delayed scan of the abdominal region was acquired at 2 hours. The SUV max and the mean Delta (Δ) SUV were calculated. The scintigraphic results were compared with the results of colonoscopy and histology and with the clinical follow-up. Thirteen out of the 39 patients did not show any significant area of FDG uptake at the whole-body scan. The remaining 26 patients showed an overall number of 27 sites of focal increased uptake, showing a mean SUV max of 6.5+3.3. Late scan of the abdomen showed vanishing spots in 11 cases. Focal and increasing FDG uptake was found in 15 subjects (for an overall number of 16 sites) with SUV max of 15.6+4 and mean Δ SUV of +26.3%±7.5%. In these cases, final diagnosis was PC in 10 patients (according to cytology or histology) and dysplastic polyp in 5 cases. No significant difference in Δ SUV was found between patients with PC and those with polypoid formations. According to our results, dual-time point imaging after carbonated water may increase the accuracy of FDG PET/CT for the imaging of PC in patients affected by CRC.

Diffuse Peritoneal Chlamydial Infection Presenting as Possible Ovarian Peritoneal Carcinomatosis in an Adolescent Female

A 17-year-old girl presented with significant abdominal ascites associated with periumbilical pain. On examination, her abdomen was found to be soft and moderately distended with left lower quadrant tenderness. Abdominal computed tomographic scan demonstrated not only ascites but also diffuse peritoneal enhancement, a left-sided enhancing adnexal mass displacing the uterus to the right, as well as omental caking. Alpha fetoprotein level was normal, whereas carcinoembryonic antigen (3.4 ng/mL) and cancer antigen 125 (315 U/mL) were mildly elevated. Based on these findings, a presumptive diagnosis of peritoneal carcinomatosis of ovarian origin was made. However, intraoperative biopsy of the left adnexal mass showed only a lymphoplasmacytic infiltrate. Chlamydial polymerase chain reaction of an intraoperative cervical sample was positive, and the final diagnosis was complicated pelvic inflammatory disease. The patient responded well to a prolonged course of antibiotics.

Role of ascites adenosine deaminase in differentiating between tuberculous peritonitis and peritoneal carcinomatosis

To investigate the usefulness of tumor markers and adenosine deaminase in differentiating between tuberculous peritonitis (TBP) and peritoneal carcinomatosis (PC). A retrospective analysis of data was performed on consecutive patients who underwent peritoneoscopic and abdominal computed tomography (CT) evaluations. Among 75 patients at the Seoul National University Hospital from January 2000 to June 2010 who underwent both tests, 27 patients (36.0%) and 25 patients (33.3%) were diagnosed with TBP and PC, respectively. Diagnosis was confirmed by peritoneoscopic biopsy. Serum c-reactive protein (7.88 ± 6.62 mg/dL vs 3.12 ± 2.69 mg/dL, P = 0.01), ascites adenosine deaminase (66.76 ± 32.09 IU/L vs 13.89 ± 8.95 IU/L, P < 0.01), ascites lymphocyte proportion (67.77 ± 23.41% vs 48.36 ± 18.78%, P < 0.01), and serum-ascites albumin gradient (0.72 ± 0.49 g/dL vs 1.05 ± 0.50 g/dL, P = 0.03) were significantly different between the two groups. Among tumor markers, serum and ascites carcinoembryonic antigen, serum carbohydrate antigen 19-9 showed significant difference between two groups. Abdominal CT examinations showed that smooth involvement of the parietal peritoneum was more common in the TBP group (77.8% vs 40.7%) whereas nodular involvement was more common in the PC group (14.8% vs 40.7%, P = 0.04). From receiver operating characteristic (ROC) curves ascites adenosines deaminase (ADA) showed better discriminative capability than tumor markers. An ADA cut-off level of 21 IU/L was found to yield the best results of differential diagnosis; sensitivity, specificity, positive predictive value, and negative predictive value were 92.0%, 85.0%, 88.5% and 89.5%, respectively. Besides clinical and radiologic findings, ascitic fluid ADA measurement is helpful in the differential diagnosis of TBP and PC.