Peritoneal Nodularity Research Articles

Disseminated Blastomycosis in a Previously Stable Crohn's Disease Patient on Infliximab Therapy

Abstract Reactivation of granulomatous diseases is a well-documented risk of biologic therapy. This case highlights a patient well controlled on chronic infliximab therapy, developing symptoms consistent with disease progression. The patient underwent a surgical laparoscopy given concern of small bowel obstruction in which diffuse, peritoneal nodularity was seen. Further staining revealed broad-budding yeast and blastomyces urinary antigen resulted as positive. The patient was treated for disseminated blastomycosis, and his symptoms completely resolved.

Peritoneal Carcinomatosis of Prostate Cancer with PSMA-targeted 18F-DCFPyL PET/CT

HomeRadiology: Imaging CancerVol. 5, No. 2 PreviousNext Images in CancerFree AccessPeritoneal Carcinomatosis of Prostate Cancer with PSMA-targeted 18F-DCFPyL PET/CTRonald Woodruff , Cameron Henry, Phillip SchererRonald Woodruff , Cameron Henry, Phillip SchererAuthor AffiliationsFrom the Philadelphia College of Osteopathic Medicine, 4170 City Avenue, Philadelphia, PA 19131 (R.W.); and Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, Tenn (C.H., P.S.).Address correspondence to R.W. (email: [email protected]).Ronald Woodruff Cameron HenryPhillip SchererPublished Online:Mar 17 2023https://doi.org/10.1148/rycan.220174MoreSectionsPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In Prostate cancer is the second most common cause of cancer-related death in men. Metastatic spread of prostate cancer frequently involves the bones (84%) and, less commonly, distant lymph nodes (10.6%) and the liver (10.2%) (1). Peritoneal spread of prostate adenocarcinoma is rarely described in the literature, especially without evidence of bony spread or other distant metastatic involvement (2,3). The cause of peritoneal involvement of prostate cancer is poorly understood. While treatment options such as surgical intervention combined with medical therapy have proven effective in preventing local disease recurrence, studies have proposed that laparoscopic prostatectomies may increase the risk of iatrogenic seeding of the peritoneum, causing disease recurrence later in life (4). Cases of peritoneal involvement in the absence of surgical intervention have also been reported, possibly revealing hematogenous or lymphatic spread as a cause. Visceral involvement in prostate cancer is known to be a poor prognostic indicator. Clinicians should consider this diagnosis when performing imaging for patients with a history of prostate adenocarcinoma (Figure).Prostate-specific membrane antigen–targeted fluorine 18 (18F) 2-(3-{1-carboxy-5-[(6-18F]fluoro-pyridine-3-carbonyl)-amino]-pentyl}-ureido)-pentanedioic acid (DCFPyL) PET/CT images in an 88-year-old man with a history of prostate adenocarcinoma who presented with worsening fatigue and abdominal distention for over a year. The patient was treated 15 years prior with prostatectomy (Gleason score was 3 + 4 = 7) and continued to receive medical management. Despite treatment, the patient’s prostate-specific antigen level was elevated to 917.61 ng/mL. For restaging, imaging was performed. (A) Coronal PET image shows diffuse intense uptake throughout the peritoneum and omentum. (B, C) Axial PET/CT images show peritoneal nodularity (white arrow), ascites (red arrow), and extensive omental nodularity and stranding (blue arrows), with no evidence of skeletal metastasis. Histologic sample of the mesentery helped confirm prostate adenocarcinoma. No further genetic or histologic testing aided the patient’s diagnosis.Download as PowerPointOpen in Image Viewer Disclosures of conflicts of interest: R.W. No relevant relationships. C.H. Leadership or fiduciary role in Society of Cardiovascular Computed Tomography (SCCT) FiRST committee. P.S. No relevant relationships.Keywords: PET/CT, Prostate, Peritoneum, Omentum, Mesentery, MetastasesAuthors declared no funding for this work.

S2046 High-Grade Mucinous Adenocarcinoma of the Appendix With Signet Features and Omental Metastasis

Introduction: Primary adenocarcinoma of the appendix is an uncommon malignancy of the gastrointestinal tract. It was first described in 1882 and constitutes around 0.12 to 2.6 cases per one million people per year. In addition, signet-ring cell carcinoma of the appendix is extremely rare, it constitutes approximately 4% of all primary appendiceal neoplasms. There are few reported cases of primary signet cell appendiceal carcinoma. In this present report, we describe a rare case of primary signet ring cell carcinoma of the appendix with omental metastases in an 81-year-old male who underwent laparoscopic appendectomy. Case Description/Methods: We present a case of an 81-year-old male who had prior negative esophagogastroduodenoscopy (EGD) and colonoscopy in 2017 who presented to an urgent care in January 2021 with abdominal pain. Lab work was unremarkable, and the patient was sent home with instructions to visit the emergency department (ED) if he experienced fever, increased abdominal pain, or blood in the stool. Patient presented to the emergency department with increased abdominal pain in April 2021, and Computed Tomography (CT) scan of abdomen and pelvis with intravenous contrast showed a cystic appendiceal lesion with right peritoneal nodularity suspicious for peritoneal carcinomatosis. Therefore, the patient underwent appendectomy the following day revealing poorly differentiated, high-grade appendiceal adenocarcinoma with signet ring features, pT4a disease. Patient had a diagnostic laparoscopy in June 2021 and was found to have diffuse peritoneal carcinomatosis. Multiple biopsies were obtained and came back positive with high-grade mucinous adenocarcinoma with signet ring features. Patient agreed to pursue systemic chemotherapy. He was initiated on Capecitabine (Xeloda) 2000 mg tab PO, twice daily for 14 days and off for 7 days. Bevacizumab (Avastin) 7.5 mg IV infusion every 3 weeks (Figure). Discussion: Patients with appendiceal neoplasms may have vague lower abdominal pain but are usually asymptomatic with incidental diagnosis on imaging or appendectomy. Signet ring adenocarcinoma of the appendix typically secretes mucin leading to metastasis throughout the peritoneum and eventual obstruction. Treatment is based on stage and histology. Surgical resection and peritoneal debulking is possible. High-grade tumors require further prospective trials to evaluate treatment, but treatment options include surgical management, HIPEC, and systemic chemotherapy.Figure 1.: Histologic examination showing a signet cell carcinoma of the appendix infiltrating the peritoneum and diaphragm. (A) right lower quadrant peritoneum biopsy, (H&E stain 100x): High grade mucinous carcinoma peritonei with signet ring cells. Pool of mucin with a cluster of epithelium that shows signs of metastatic carcinoma (enlarged nuclei, atypia, pleomorphic changes). (B, C, and D) Right diaphragm peritoneum biopsy. High grade mucinous carcinoma peritonei with signet ring cells. Image B at 100x, C at 200x, and D at 400x. (E & F) immunohistochemical cytokeratin stain (AE1/AE3) shows strong positivity of high grade carcinoma. E at 100x, and F at 400x.

Guideline No. 403: Initial Investigation and Management of Adnexal Masses.

To aid primary care physicians, emergency medicine physicians, and gynaecologists in the initial investigation of adnexal masses, defined as lumps that appear near the uterus or in or around ovaries, fallopian tubes, or surrounding connective tissue, and to outline recommendations for identifying women who would benefit from a referral to a gynaecologic oncologist for further management. Gynaecologists, obstetricians, family physicians, general surgeons, emergency medicine specialists, radiologists, sonographers, nurses, medical learners, residents, and fellows. Adult women 18 years of age and older presenting for the evaluation of an adnexal mass. Women with adnexal masses should be assessed for personal risk factors, history, and physical findings. Initial evaluation should also include imaging and laboratory testing to triage women for management of their care either by a gynaecologic oncologist or as per SOGC guideline no. 404 on the initial investigation and management of benign ovarian masses. A search of PubMed, Cochrane Wiley, and the Cochrane systematic reviews was conducted in January 2018 for English-language materials involving human subjects published since 2000 using three sets of terms: (i) ovarian cancer, ovarian carcinoma, adnexal disease, ovarian neoplasm, adnexal mass, fallopian tube disease, fallopian tube neoplasm, ovarian cyst, and ovarian tumour; (ii) the above terms in combination with predict neoplasm staging, follow-up, and staging; and (iii) the above two sets of terms in combination with ultrasound, tumour marker, CA 125, CEA, CA19-9, HE4, multivariable-index-assay, risk-of-ovarian-malignancy-algorithm, risk-of-malignancy-index, diagnostic imaging, CT, MRI, and PET. Relevant evidence was selected for inclusion in descending order of quality of evidence as follows: meta-analyses, systematic reviews, guidelines, randomized controlled trials, prospective cohort studies, observational studies, non-systematic reviews, case series, and reports. Additional articles were identified through cross-referencing the identified reviews. The total number of studies identified was 2350, with 59 being included in this review. The content and recommendations were drafted and agreed upon by the authors. The Executive and Board of the Society of Gynecologic Oncology of Canada reviewed the content and submitted comments for consideration. The Board of Directors of the Society of Obstetricians and Gynaecologists of Canada approved the final draft for publication. The quality of evidence was rated using the criteria described in the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology framework (Table A1 of Online Appendix A). See Table A2 of Online Appendix A for the interpretation of strong and weak recommendations. The summary of findings is available upon request. Adnexal masses are common, and guidelines on how to triage them and manage the care of patients presenting with adnexal masses will continue to guide the practice of primary care providers and gynaecologists. Ovarian cancer outcomes are improved when initial surgery is performed by a gynaecologic oncologist, likely as a result of complete surgical staging and optimal cytoreduction. Given these superior outcomes, guidelines to assist in the triage of adnexal masses and the referral and management of the care of patients with an adnexal mass are critical. RECOMMENDATIONS (GRADE RATINGS IN PARENTHESES).

1716-P: MODY5 and Serous Ovarian Carcinoma in 17q12 Recurrent Deletion Syndrome

Background: Maturity onset diabetes of the young type 5 (MODY5) is due to a mutation in the hepatocyte nuclear factor 1b (HNF1b) gene on chromosome 17q12. HNF1b mutations have been found in clear cell ovarian carcinomas (CCOC) while non-CCOC express this mutation rarely. 17q12 recurrent deletion syndrome presents with urogenital anomalies, MODY5, neurodevelopmental and psychiatric disorders. We report a patient with 17q12 recurrent deletion syndrome with MODY5, uterine abnormalities and low grade serous ovarian cancer. Clinical Case: The female proband was diagnosed with diabetes at age 12. GAD65, islet cell and insulin auto-antibodies were negative, C-peptide was 2.7 ng/mL. Childhood history included strabismus, depression and chronic transaminitis with unremarkable liver biopsy. Mother’s medical history was notable for single kidney, partially-septated uterus, and diabetes. At age 25, the patient presented with abdominal pain. CT showed pancreatic atrophy, ascites, omental and peritoneal nodularity and calcifications. Tumor markers were normal except an elevated CA-125 of 240 U/mL. Short stature was noted, height 147 cm, BMI 27 kg/m2. Laparoscopy revealed bicornuate uterus, 2 cervices and vaginal septum. She underwent TAH-BSO, lymph node dissection and omentectomy for a stage IIIC low grade serous ovarian carcinoma. Chromosomal microarray analysis of the tumor revealed a pathogenic ∼1.8 Mb loss of 17q12, denoted arr[hg19] 17q12(34477479_36283807)x1. Conclusion: While 17q12 has been described as a susceptibility locus in some ovarian cancers, ovarian cancer predisposition is not a reported feature of MODY5 or 17q12 recurrent deletion syndrome. The disease association reported here suggests that women with MODY5 should have periodic evaluation for ovarian cancer in addition to screening for gut and urogenital tract abnormalities. Patients with diabetes plus urogenital tract abnormalities or 17q12 deletion in an ovarian tumor should have genetic evaluation for MODY5. Disclosure L. Hollar: None. M. Salam: None. P.H. Thaker: Advisory Panel; Self; Clovis. Consultant; Self; AbbVie Inc., Celsion, Tesaro, UpToDate. Research Support; Self; Celsion, Merck & Co., Inc. Speaker’s Bureau; Self; Merck & Co., Inc., Tesaro. J.B. McGill: Advisory Panel; Self; Boehringer Ingelheim Pharmaceuticals, Inc., Gilead Sciences, Inc., Novo Nordisk Inc., Sanofi US. Research Support; Self; Dexcom, Inc., Medtronic, Novartis AG, Sanofi US. Speaker's Bureau; Self; Aegerion Pharmaceuticals, Dexcom, Inc., Janssen Pharmaceuticals, Inc., MannKind Corporation.

A Case of Intestinal Tuberculosis Masquerading as Crohnʼs Disease in a Patient Treated With Infliximab

Intestinal TB (ITB) is a known mimicker of Crohn's disease, and oftentimes confounds even seasoned gastroenterologists in endemic countries. Accurately distinguishing the two disease entities is critical to the proper management of these patients. Here we present the case of a recent immigrant from the Philippines who had been diagnosed with Crohn's disease by a referring gastroenterologist, and subsequently started on infliximab. A 47-year-old male who recently moved here from the Philippines presented to the Emergency Department of our hospital in septic shock. His clinical history was notable the recent development of abdominal pain and diarrhea, for which he had been seen by a community gastroenterologist. It was there that he was first diagnosed with Crohn's disease, and started on a steroid burst without any improvement in his clinical symptoms. He was therefore started on infliximab. Prior to this, the patient was tested for tuberculosis with an interferon-gamma release assay (IGRA) which returned indeterminate, as well as a tuberculin skin test (TST) which was negative. In the ED, CT chest/abdomen revealed pleural effusions, liver lesions, ileocolitis, and peritoneal nodularity. A workup with liver lesion biopsy, thoracentesis, and paracentesis was negative for malignant cells but instead stained positive for acid-fast bacilli (AFB). The patient was diagnosed with septic shock due to disseminated TB and started on anti-mycobacterial therapy. Unfortunately, the patient's hospital course was complicated by the development of a colonic perforation requiring exploratory laparotomy with ileocolonic resection. Pathology of the resected ileum and colon showed both caseating and non-caseating granulomatous inflammation with numerous AFB consistent with intestinal tuberculosis (ITB). After an extended ICU course, the patient was discharged home on anti-mycobacterial therapy. This case illustrates the clinical dilemma which may be encountered in distinguishing between Crohn's disease and intestinal tuberculosis. Clinical diagnosis was confounded by an indeterminate IGRA test and a negative TST, and ultimately the decision to initiate infliximab therapy led to poor outcomes in this patient. It is prudent to maintain a heightened index of suspicion, especially in cases of recent arrival from endemic countries or other risk factors.

Extrapulmonary Small Cell Carcinoma: An Unfortunate Case of Metastatic Disease

Abstract A 48- year-old man presented with weight loss and 3 weeks of right sided lower abdominal pain. Liver ultrasound and contrast-enhanced computed tomographic scan of the chest, abdomen, and pelvis revealed a 6.8 x 4.3 cm mass like thickening of ascending colon, with numerous hepatic lesions, enlarged mesenteric lymph nodes, peritoneal nodularity and multiple small (2-4 mm) pulmonary nodules concerning for widely metastatic disease (Figure A). A colonoscopy revealed an ulcerated right colon mass obliterating the lumen (Figure B). Histologic examination showed highly proliferative round cells with a high nuclear to cytoplasmic ratio with adjacent high grade adenomatous change (Figure C). Immunohistochemical stain was positive for synaptophysin (Figure D). Histologic examination of a liver lesion revealed similar histology. Findings were consistent with high-grade metastatic extrapulmonary small cell carcinoma (EPSCC), a rare neuroendocrine carcinoma. Data from the National Cancer Institute's Surveillance, Epidemiology and End Results program from 1992 to 2010 reflects the rarity of EPSCC of the colon and rectum with an incidence rate of

Chlamydia Peritonitis and Ascites Mimicking Ovarian Cancer.

Background. Pelvic inflammatory disease (PID) rarely results in diffuse ascites. Severe adhesive disease secondary to PID may lead to the formation of inclusion cysts and even pelvic peritoneal nodularity due to postinflammatory scarring and cause an elevation of serum CA-125 levels. The constellation of these findings may mimic an ovarian neoplasm. Case. We report a case of a 22-year-old female who presented with multiple pelvic cysts and diffuse ascites due to Chlamydia trachomatis infection. The initial gynecologic exam did not reveal obvious evidence of PID; however, a positive Chlamydia trachomatis test, pathologic findings, and the exclusion of other etiologies facilitated the diagnosis. Conclusion. Chlamydia trachomatis and other infectious agents should be considered in the differential diagnosis of a young sexually active female with abdominal pain, ascites, and pelvic cystic masses. Thorough workup in such a population may reduce the number of more invasive procedures as well as unnecessary repeat surgical procedures.

A surgical case of haemothorax

An 83-year-old female presented with a 6-day history of painless jaundice, anorexia, dark urine, steatorrhea and weight loss of 10 kg over the past year. The only past medical history was a monoclonal gammopathy of unknown significance. She was a never-smoker and did not drink alcohol. On examination, she was apyrexial and normotensive. She was clinically jaundiced, and had 4 cm non-tender hepatomegaly. Initial blood tests revealed a bilirubin concentration of 166 μmol·L−1 (normal range 0–21 μmol·L−1), alkaline phosphatase of 371 units·L−1 (normal range 30–150 units·L−1) and an alanine transaminase of 145 units·L−1 (normal range 0–40 units·L−1). Her renal function and inflammatory markers were normal. An abdominal ultrasound showed intra-hepatic biliary dilatation, suggesting obstruction in the lower common bile duct. She went on to have a computed tomography (CT) scan of her abdomen, which showed a small amount of ascites, peritoneal nodularity, bile duct dilatation and a mass in the body and tail of the pancreas involving the aorta and left adrenal gland. Several attempts at a percutaneous trans-hepatic cholangiogram (PTC) were made, but the radiologist was unable to cannulate the biliary ducts. A stent was then inserted at endoscopic retrograde cholangiopancreatography (ERCP) and a biopsy of the mass was carried out. 24 h later the patient deteriorated with pyrexias, hypotension and new onset atrial fibrillation with a fast ventricular rate. Her white blood cell count rose to 16.5×109 cells·L−1 from 12.4×109 cells·L−1 and her C-reactive protein to 52 mg·L−1 (normal level less than 5 mg·L−1). Her haemoglobin dropped from 116 g·L−1 to 93 g·L−1. Her kidney and liver function tests also deteriorated and a chest radiograph showed a new right pleural effusion (fig. …

Diffuse malignant peritoneal mesothelioma

Mesothelioma often originates in the pleura and less frequently in the peritoneum. This article describes a rare case of diffuse malignant peritoneal mesothelioma in a 54-year-old male construction worker who was admitted to our hospital with a 2-month history of progressive abdominal distention. Abdominal computed tomography revealed extensive peritoneal nodularity and omental cake along with massive ascites. Imaging findings initially suggested peritoneal carcinomatosis, primary peritoneal carcinoma, and tuberculous peritonitis. Laparoscopic biopsy of the omentum and peritoneum confirmed the diagnosis of malignant peritoneal mesothelioma of epitheloid type. Although systemic chemotherapy was administered, no tumor regression was found. The patient finally died of nosocomial infection.

Prognostic significance of computed tomography defined ascites in advanced gastric cancer.

PurposeThe aim of this study was to investigate the clinicopathologic features and prognosis in patients with computed tomography (CT) findings of ascites, with a focus on the correlation with peritoneal carcinomatosis.MethodsThis study included a total of 157 patients who underwent surgery for advanced gastric cancer from 2003 to 2008 at the Department of Surgery, Hallym University Kangdong Sacred Heart Hospital, Seoul, Korea, which were analyzed retrospectively.ResultsFourteen patients (8.9%) presented ascites on their CT scan. Among them, 10 patients had peritoneal carcinomatosis, and showed significant difference with CT ascites positive group in the incidence of peritoneal carcinomatosis. The presence of CT ascites was significantly correlated with pathologic T stage, tumor size, histologic type, CT T and N stages, CT peritoneal nodularity and curability of surgery, statistically. The prognosis of CT ascites positive group was much poorer in the total advanced gastric cancer patients (P < 0.001), as well as in patients with pathologic T4 (P = 0.002). Also in patients without peritoneal carcinomatosis, CT ascites positive subgroup tended to have a worse prognosis than CT ascites negative subgroup (P = 0.086). Tumor size, CT T and N stages and the presence of CT peritoneal nodularity and ascites influenced the prognosis significantly; among which, if a tumor size larger than 5 cm, CT T4 stage and the presence of CT ascites were identified as independent prognostic factors.ConclusionThe presence of ascites was closely associated with peritoneal metastasis, and was the most significant independent prognostic factor in advanced gastric cancer in the present study.

Multidetector CT predictors of incomplete resection in primary cytoreduction of patients with advanced ovarian cancer

This study was designed to develop a preoperative predictor model using multidetector CT (MDCT) imaging findings for the prediction of surgical outcome in patients with advanced epithelial ovarian cancer (EOC). Seventy-seven patients with advanced EOC who had preoperative MDCT and who had undergone primary cytoreductive surgery between January 1999 and June 2008 were enrolled in the study. All MDCT examinations were analysed retrospectively, assessing nine imaging features without knowledge of the operative findings. The complete debulking rate and optimal debulking rate were 42.5% and 93.2%, respectively. Based on the use of univariate and multivariate analysis, one imaging feature that showed the presence of upper abdominal ascites was significantly associated with incomplete tumour resection (P = 0.019 on univariate analysis, P = 0.04 on multivariate analysis). The combination of the MDCT findings that showed the presence of upper abdominal ascites and diffuse subdiaphragmatic peritoneal nodularity was associated with an incomplete resection of a tumour (P = 0.04; specificity 80.0%; positive predictive value 76.9%). It is important that emphasis on the upper abdominal sites of the tumour is helpful when reporting preoperative MDCT results.