Extraperitoneal Spread Research Articles

Pseudomyxoma peritonei: The struggle of a lifetime and the hope of a cure - a rare diagnosis with review of the literature.

Pseudomyxoma peritonei is a rare pathological condition characterized by mucinous tumor tissue implants on the peritoneal surface. Although the cause of Pseudomyxoma peritonei has been extensively studied, the prevailing agreement is that it stems from mucinous tumors that occur in the ovaries or appendix. The tumor tissue typically remains localized to the peritoneum and does not exhibit extraperitoneal spread. Patients with Pseudomyxoma peritonei may present with symptoms such as abdominal pain, bloating, loss of appetite, and shortness of breath. Computerized Tomography is commonly used for diagnostic purposes. The treatment of Pseudomyxoma peritonei typically involves surgical evacuation of the tumoral tissue, followed by cytoreduction and Hyperthermic Intraperitoneal Chemotherapy. While effective treatment options are available, some patients may require repeated surgeries over an extended period. This paper reports on a case study of a patient with a history of recurrent Pseudomyxoma peritonei, necessitating multiple surgical interventions over a decade. The paper concludes with a review of the relevant literature.

A case series of Extra-peritoneal spread of perianal abscess: a rare complication of perianal abscess - Experience from a tertiary care centre in India.

Extra-peritoneal spread of perianal abscess is a rare form of anorectal disease responsible for significant morbidity. We present a case series of 10 patients who presented with abdominal pain as a common symptom. 9 of 10 were not diagnosed at presentation to index centre. A proper examination of the perianal region as well as abdomen can help us suspect this condition clinically and can be confirmed with cross sectional imaging. Draining seton with adequate drainage of both perianal and extra-peritoneal component is the key treatment.

Multicystic mesothelioma has malignant potential: its grounds and mechanisms of peritoneal metastasis

From 2009 to 2016, 9 female patients with multicystic peritoneal mesothelioma (MCPM) underwent 11 cytoreductive surgeries (CRS). Mean age at diagnosis was 50.6 (range, 43-71). Mean peritoneal cancer index was 8.9 (range, 2~33). Most frequent peritoneal sector involved was pelvic peritoneum in 7 patients, and greater omentum was involved in 6 patients. Eight and 1 patients had complete CRS and incomplete CRS, respectively. Except 1 patient, 8 patients had multiple cysts on different peritoneal sectors, and diffuse involvement on peritoneal surface was found in 2 patients No patients had lymph node metastasis or extraperitoneal spread. However, 3 patients showed pushing invasion to small bowel mesentery, colon, umbilicus and stomach. Median- follow-up was 46 months (range 4-120). At the time of the present analysis, all patients were alive. One patient recurred in peritoneal cavity 47 month after complete cytoreduction. Peritoneal free-floating cysts (PFFC) were found in 8 of 9 (88.9%) patients. Sizes of PFFC ranged from 1 mm to 2 cm in diameter and the inner surfaces were covered with mesotheliallike cells. MIB-1 labeling rates of PFFC ranged from 0.1% to 2.0%. These results indicate that PFCC may attach on the orifice of subperitoneal lymphatic vessels, and may become metastatic. The present study strongly suggests that MCPM has a potentially malignant behavior. This category of disease is composed of 2 types: diffuse type and localized type with borderline malignant potential. PFFC have an important role in the formation of peritoneal metastasis.

Use of 18F-FDG PET/CT in the preoperative evaluation of patients diagnosed with peritoneal carcinomatosis of ovarian origin, candidates to cytoreduction and hipec. A pending issue

PurposeTo evaluate the clinical usefulness of the results obtained with 18F-FDG PET/CT in relation to CT in the preoperative staging of patients with peritoneal carcinomatosis secondary to primary or recurrent ovarian cancer candidates to cytoreductive surgery and hyperthermic intraoperative intraperitoneal chemotherapy (HIPEC). Material and methodsA retrospective study comparing the results obtained with CT and 18F-FDG PET/CT in the preoperative evaluation of a series of 59 patients was performed. In all patients the peritoneal carcinomatosis index (PCI) was determined by preoperative radiological CT and 18F-FDG PET/CT and compared with surgical PCI, which was considered as reference. ResultsOf the 59 patients studied, in 55 peritoneal carcinomatosis presences were confirmed (4 patients had complete responses to neoadjuvant chemotherapy). The mean surgical, CT and 18F-FDG PET/CT PCI was 9.46±7.70, 3.69±3.96 and 2.25±1.02, respectively. In the global disease detection, CT showed a higher positive likelihood ratio (LR+) than 18F-FDG PET/CT (15.3, 95% CI 8.35–28.04 vs. 3.47, 95% CI 3.36–5.11) and a lower negative likelihood ratio (LR-) than 18F-FDG PET/CT (0.67, 95% CI 0.61–0.73 vs. 0.82, 95% CI 0.76–0.88). In every region of the abdomen the CT showed a greater LR+ than 18F-FDG PET/CT and a lower LR- than 18F-FDG PET/CT. ConclusionsCT showed the best diagnostic results compared to 18F-FDG PET/CT to confirme the presence of peritoneal disease. The lower performance of the 18F-FDG PET/CT suggests that the main utility of 18F-FDG PET/CT is to evaluate a possible metastatic extraperitoneal spread of the disease.

Recurrent ovarian cancer metastatic to the bone : Case report

In patients with gynecologic malignancies, bone metastases are unusual and generally occur in a more advanced stage of the disease with extended local invasion of the primary site and/or parenchymal metastasis. In ovarian cancer, the main route of spread is intraperitoneal implantation and loco-regional invasion, whereas extraperitoneal spread usually implies advanced disease. Bone metastasis from ovarian cancer is rare and occurs in approximately 1% of primary or recurrent disease. The prognosis of cases with bone metastasis is poor. We report a patient with metastases to the sternum and a rib after prolonged treatment and a patient with recurrent ovarian cancer metastatic to the sacrum 8 months after primary treatment.

Carcinoma of the Fallopian Tube: Clinicopathologic Study of 151 Patients Treated at the Norwegian Radium Hospital

BACKGROUND The objective of the current study was to increase insight into the biology of fallopian tube carcinoma through an analysis of possible clinical and pathologic determinants of prognosis and to formulate recommendations with regard to a more optimal therapeutic approach for patients with this rare disease. METHODS A study was performed of the pathology specimens and clinical case records from 151 patients with fallopian tube carcinoma who were treated consecutively. Both univariate and multivariate analyses of possible prognostic factors were performed for the whole group and for the subgroup of 41 patients with Stage I disease. The possible significance of serum CA-125 levels as a tumor marker and a marker of response to platinum-containing chemotherapy was evaluated. RESULTS In multivariate analysis, disease stage, the presence of residual tumor, and a hydrosalpinx-like appearance of the fallopian tube were of independent prognostic significance for the whole cohort. For patients with Stage I disease, the depth of infiltration in the tubal wall and intraoperative tumor rupture were of independent prognostic significance. The marked tendency of this disease for extraperitoneal spread, even in apparently early stages, was confirmed. In 37 evaluable, platinum-naive patients, an overall response rate of 70% was obtained with platinum-based chemotherapy, with a median response duration of 12.5 months. In view of its low efficacy and high rate of serious complications, the use of postoperative radiotherapy in the treatment of patients with fallopian tube carcinoma is no longer recommended. Serum CA-125 level measurements in fallopian tube carcinoma patients have the same significance as tumor and surrogate markers of response as in ovarian carcinoma patients. CONCLUSIONS Prognostic factors in patients with early stage (Stages 0 and I) fallopian tube carcinoma seem to differ from those in patients with early stage ovarian carcinoma. For patients with more advanced stage disease, due to the striking similarities in prognostic and clinical characteristics between the two diseases, the authors recommend that the treatment and follow-up strategies for patients with ovarian carcinoma be adopted in the management of patients with fallopian tube carcinoma. Cancer 2000;89:2076–84. © 2000 American Cancer Society.

Occult tumor cells in bone marrow of patients with locoregionally restricted ovarian cancer predict early distant metastatic relapse.

Based on conventional tumor staging, primary ovarian cancer is viewed as an intraperitoneal disease that rarely spreads to extraperitoneal organs. However, autopsy studies reveal a much higher rate of occult metastasis, indicating that extraperitoneal spread occurs with much greater frequency than previously appreciated. Consequently, we investigated the incidence of early hematogenous dissemination and its association with distant disease-free and overall survival. Bone marrow aspirates from 108 patients newly diagnosed with International Federation of Gynecology and Obstetrics stage I to III ovarian cancer were prospectively analyzed with the novel anti-cytokeratin (CK) antibody A45-B/B3. We investigated the frequency of CK-positive tumor cells in bone marrow and their effect on prognosis in relation to established risk factors for tumor progression. Tumor cells in bone marrow were detected in 32 (30%) of 108 patients. A CK-positive finding was unrelated to established risk parameters, except for poor nuclear grading of the primary tumor. At a median follow-up of 45 months (range, 12 to 77 months), the presence of occult metastatic cells in bone marrow was associated with the occurrence of clinically overt, extraperitoneal (predominantly extraskeletal) distant metastasis (relative risk [RR], 16.5; 95% confidence interval [CI], 6.2 to 56.9; P < .0001) and death from cancer-related causes (RR, 2.3; 95% CI, 1.2 to 4.3; P = .01). Multivariate analysis identified a positive bone marrow finding as an independent prognostic factor of reduced distant disease-free survival for all patients (RR, 13.8; 95% CI, 5.4 to 52.9; P < .0001) and for the 64 stage R0-1 patients (RR, 7.3; 95% CI, 1.5 to 56.8; P = .0021). Our data signal that hematogenous dissemination of tumor cells occurs early and throughout all stages of ovarian cancer. The clinical significance of our findings is supported by the unfavorable prognosis in association with the presence of occult metastatic cells, especially in those patients who received an effective locoregional therapy.

Carcinoma of the fallopian tube

The objective of the current study was to increase insight into the biology of fallopian tube carcinoma through an analysis of possible clinical and pathologic determinants of prognosis and to formulate recommendations with regard to a more optimal therapeutic approach for patients with this rare disease. A study was performed of the pathology specimens and clinical case records from 151 patients with fallopian tube carcinoma who were treated consecutively. Both univariate and multivariate analyses of possible prognostic factors were performed for the whole group and for the subgroup of 41 patients with Stage I disease. The possible significance of serum CA-125 levels as a tumor marker and a marker of response to platinum-containing chemotherapy was evaluated. In multivariate analysis, disease stage, the presence of residual tumor, and a hydrosalpinx-like appearance of the fallopian tube were of independent prognostic significance for the whole cohort. For patients with Stage I disease, the depth of infiltration in the tubal wall and intraoperative tumor rupture were of independent prognostic significance. The marked tendency of this disease for extraperitoneal spread, even in apparently early stages, was confirmed. In 37 evaluable, platinum-naïve patients, an overall response rate of 70% was obtained with platinum-based chemotherapy, with a median response duration of 12.5 months. In view of its low efficacy and high rate of serious complications, the use of postoperative radiotherapy in the treatment of patients with fallopian tube carcinoma is no longer recommended. Serum CA-125 level measurements in fallopian tube carcinoma patients have the same significance as tumor and surrogate markers of response as in ovarian carcinoma patients. Prognostic factors in patients with early stage (Stages 0 and I) fallopian tube carcinoma seem to differ from those in patients with early stage ovarian carcinoma. For patients with more advanced stage disease, due to the striking similarities in prognostic and clinical characteristics between the two diseases, the authors recommend that the treatment and follow-up strategies for patients with ovarian carcinoma be adopted in the management of patients with fallopian tube carcinoma.

Peritoneal mesothelioma: treatment approach based on natural history.

A more modern treatment strategy for diffuse malignant peritoneal mesothelioma may be suggested (figure 3). Clinical suspicion of diffuse malignant mesothelioma (peritoneal carcinomatosis) calls for laparoscopy with evaluation of parietal and visceral peritoneum and multiple biopsies sufficient for definitive histologic diagnosis. Cytologic examination of ascitic fluid is not likely to be of benefit. CT of chest, abdomen, and pelvis is needed for evaluation of visceral involvement and the presence of distant metastases. Contrast enhancement of the gastrointestinal and urinary tract is necessary with the CT. Additional radiologic techniques for detection of distant metastases should be used if there are clinical or laboratory signs of extraperitoneal spread. After histologic diagnosis and extent of tumor spread have been documented, and if no symptoms of intestinal obstruction are present, the patient may be subjected to two to three courses of induction intraperitoneal chemotherapy. This will provide the clinician with important information on tumor response to chemotherapy, minimize tumor accumulation on bowel surfaces, and provide time for surgical conditioning. The time devoted to induction chemotherapy will allow occult distant metastases to be detected. In patients with a response or stable disease, cytoreductive surgery is attempted approximately 2 months after completion of induction chemotherapy. Surgery must be aimed at achieving complete or near-complete cytoreduction through the use of peritonectomy procedures [46,47]. Additional intraperitoneal chemotherapy should be administered intraoperatively and in the early postoperative period (figure 3). This treatment strategy may be the most feasible one according to existing knowledge of the natural history of diffuse malignant peritoneal mesothelioma. Only further phase II clinical trials can reveal the extent to which it is beneficial. Because of the rare occurrence of this disease, the quickest answer would come as a result of cooperative study by several groups experienced in these treatment modalities.

Pseudomyxoma peritonei: a review

Pseudomyxoma peritonei is an uncommon clinical entity. It is characterized by massive abdominal distension by gelatinous material. It is produced by mucous-secreting peritoneal implants which are secondary, usually, to an ovarian or appendiceal neoplasm. Although remaining localized to the peritoneal cavity and hence thought to be a benign process, the clinical course of the disease, the association, in the majority of cases, with a malignant primary tumor, and the report of a small number of cases with extraperitoneal spread lends support to the belief that this is a malignant disease. Five-year survival is 68% with ten-year survival at 52%. Despite the utilization of numerous adjuvant therapies, the mainstay of treatment remains complete surgical debulking at initial presentation followed by palliative debulking for symptomatic relief.

Cerebral metastases from ovarian carcinoma

Apart from choriocarcinoma, involvement of the central nervous system (CNS) by gynecologic malignancy is rare. A 10-year retrospective review at the University of Washington Medical Center (Seattle, WA) and Swedish Hospital and Medical Center Tumor Registry (Seattle, WA) identified 14 patients with cerebral metastases from ovarian carcinoma. Median age at diagnosis of cerebral metastases was 52.5 years. Median interval from the diagnosis of ovarian carcinoma to the diagnosis of CNS metastases was 14.5 months. Seven patients had received cisplatin therapy before CNS relapse. Seven patients underwent second-look procedures before developing CNS metastases; in three, results were negative. Eight patients had evidence of extraperitoneal spread to other sites at the time of CNS relapse. Clinical manifestations included motor weakness, seizures, headache, confusion, and speech disturbance. All lesions were contrast enhancing on computed tomography (CT) scans and were located in the cerebral hemispheres. Nine patients had single lesions, five of whom underwent surgical resection of the lesion with histologic confirmation of metastases from the primary site. Median survival was 2 months in patients receiving radiation therapy alone and 17 months in patients who received surgery and radiation. Median survival of the entire series was 3 months. The presence of multiple cerebral metastases or evidence of extraperitoneal spread elsewhere in the body was adversely associated with survival. The prognosis of patients with cerebral metastases from ovarian carcinoma appears poor. However, early diagnosis by routine CT scanning followed by surgical resection and radiation may improve overall survival in a select group of patients.

PSEUDOMYXOMA PERITONEI

Pseudomyxoma peritonei is a term that began life as a description of a pathological entity; but now, by usage, it refers to a clinical syndrome of massive accumulation of gelatinous ascites, with long survival and an absence of lymphatic, hepatic parenchymal, and extraperitoneal spread. The peritoneal cavity may contain cell-free pseudomucin, or there may be epithelial elements that vary in appearance from benign to frankly malignant. It seems likely that malignant tumours of the appendix or ovary cause most examples. Relatively good general health is usually preserved until abdominal distension makes life intolerable. The treatment is basically surgical, and consists of removal of free pseudomucin at laparotomy, together with excision of as much solid tumour as possible. Supplementary local chemotherapy seems to improve the prognosis, but systemic chemotherapy and local radiotherapy have no proven place in management. The clinical and pathological details of three previously unreported cases are included in this report.

SURGICAL MANAGEMENT OF COMPLICATED AND EXTRAPERITONEAL SPREAD OF CARCINOMA OF THE COLON AND RECTUM.

SURGICAL MANAGEMENT OF COMPLICATED AND EXTRAPERITONEAL SPREAD OF CARCINOMA OF THE COLON AND RECTUM.