1 Case presentation 新光醫院核子醫學科葉力豪2010/3/13. 2 Case 1: History 70 y/o female 70 y/o female PH: PH: HBV & HCV carrier HBV & HCV carrier DM DM CC: Lower

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Case presentationCase presentation

新光醫院核子醫學科新光醫院核子醫學科葉力豪葉力豪

2010/3/132010/3/13

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Case 1: HistoryCase 1: History

70 y/o female70 y/o female PH:PH:

HBV & HCV carrierHBV & HCV carrier DMDM

CC: CC: Lower abdominal painLower abdominal pain for one month for one month Dull and intermittentDull and intermittent No aggravating or relieving factorsNo aggravating or relieving factors

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Gynecology sonography (2008/9/24):Gynecology sonography (2008/9/24): WNL, WNL, Bil. Adnexa: invisibleBil. Adnexa: invisible

Colonoscopy (2008/9/26): Colonoscopy (2008/9/26): internal hemorrhoidinternal hemorrhoid

U/A: normalU/A: normal CT of abdomen and pelvis (2009/10/29):CT of abdomen and pelvis (2009/10/29):

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Omental thickening (Omental cake)

nodularity

Peritoneal carcinomatosis

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nodularity

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Tumor marker (2008/10/31):Tumor marker (2008/10/31): CEA: 0.7 (0~5)CEA: 0.7 (0~5) CA125: 93.91 (0~35) CA125: 93.91 (0~35) CA19-9: 7.27 (0~27)CA19-9: 7.27 (0~27)

Gynecology sonography (2008/11/5): Gynecology sonography (2008/11/5): Bilateral adnexa: invisibleBilateral adnexa: invisible

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FDG-PET/CT (2008/11/6)

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Omental thickening

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Omental thickening

1010

Omental thickening

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Impression: Primary peritoneal carcinomaImpression: Primary peritoneal carcinoma Laparotomy (2008/11/13):Laparotomy (2008/11/13):

Large Large omental cakeomental cake adhesion to anterior peritoneal adhesion to anterior peritoneal layer layer

SomeSome ascitesascites < 50 cc< 50 cc Nodularity over whole peritoneumNodularity over whole peritoneum, esp. cul-de-sac, , esp. cul-de-sac,

bilateral pelvic cavity and anterior bladder wallbilateral pelvic cavity and anterior bladder wall Bilateral adnexa: Bilateral adnexa: grossly normalgrossly normal, about , about 2x1cm(Rt)2x1cm(Rt)

& & 1.5x1cm(Lt)1.5x1cm(Lt)

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Operative procedures: Operative procedures: Bil. salpingo-oophorectomy + omentectomy + Bil. salpingo-oophorectomy + omentectomy +

retroperitoneal tumor biopsy + washing retroperitoneal tumor biopsy + washing cytology cytology

Pathology: Pathology: Left ovary: Serous cystadenocarcinomaLeft ovary: Serous cystadenocarcinoma Right ovary: Negative for malignancyRight ovary: Negative for malignancy Omentum metastasesOmentum metastases (>2cm, T3c, Stage IIIC)(>2cm, T3c, Stage IIIC)

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49 y/o female49 y/o female Past History:Past History:

AsthmaAsthma HyperthyroidismHyperthyroidism Major depressionMajor depression G4P2, G4P2, PerimenopausePerimenopause Appendicitis s/p appendectomyAppendicitis s/p appendectomy Bilateral ovarian chocolate cysts s/p Bilateral ovarian chocolate cysts s/p

operationoperation

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Chief Complaint (2008/12):Chief Complaint (2008/12): Lower abdominal painLower abdominal pain CA-125: 92.3CA-125: 92.3 (normal < 35) (normal < 35)

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Gyn echo (2008/12/26) :Gyn echo (2008/12/26) : Uterine myomaUterine myoma R’t ovary: 2.46 x 1.59 cmR’t ovary: 2.46 x 1.59 cm Suspicious left ovarian cyst: 2.68 x 1.66cmSuspicious left ovarian cyst: 2.68 x 1.66cm

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2009/4/29:2009/4/29: CA-125: 93.71CA-125: 93.71 U/ml (normal < 35) U/ml (normal < 35) CA-153: 64.08CA-153: 64.08 U/ml (normal < 30) U/ml (normal < 30) Breast echo: normalBreast echo: normal Gyn echo:Gyn echo:

R’t ovary : 1.94 x 1.46 cmR’t ovary : 1.94 x 1.46 cm L’t ovary : unremarkableL’t ovary : unremarkable Adenomyosis of uterusAdenomyosis of uterus

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2009/6/23

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Omental thickening

Omental thickening

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2020

Omental thickening

Cul-de-sac

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Cul-de-sac

Omental thickening

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Omental thickening

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Operation at Operation at 和信醫院和信醫院 :: Total abdominal hysterectomy + bilateral Total abdominal hysterectomy + bilateral

salpingo-oophorectomy + pelvic LN dissection salpingo-oophorectomy + pelvic LN dissection + Cul-de-sac & peritoneal tumor resection + + Cul-de-sac & peritoneal tumor resection + omentectomy omentectomy

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Patholgy:Patholgy: Bil. Ovary & fallopian tube:Bil. Ovary & fallopian tube:

High grade papillary serous carcinomaHigh grade papillary serous carcinoma R’t ovary: R’t ovary: 2.5 x 2 x 1.5 cm2.5 x 2 x 1.5 cm L’t ovary : L’t ovary : 2.5 x 1.1 x 0.5 cm2.5 x 1.1 x 0.5 cm

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Cul-de-sac, peritoneum, omentum:Cul-de-sac, peritoneum, omentum: High grade papillary serous carcinomaHigh grade papillary serous carcinoma

Serosal surface of the uterus, pelvic LNs: Serosal surface of the uterus, pelvic LNs: metastatic adenocarcinomametastatic adenocarcinoma (N1 stage (N1 stage Stage Stage

IIIC at least)IIIC at least) Uterus:Uterus:

four myoma (measuring up to 3.4 cm)four myoma (measuring up to 3.4 cm)

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DiscussionDiscussion

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Peritoneal CarcinomatosisPeritoneal Carcinomatosis

Definition:Definition:

Extensive, or very widespread, metastasis Extensive, or very widespread, metastasis of cancerous tumors onto the of cancerous tumors onto the inside inside surfaces (peritoneum)surfaces (peritoneum) of the abdomen. of the abdomen.

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Occurs commonly with abdominopelvic Occurs commonly with abdominopelvic tumorstumors

Most common tumors:Most common tumors: Ovarian carcinoma (female)Ovarian carcinoma (female) Gastric cancer Gastric cancer Pancreas cancerPancreas cancer Colon cancerColon cancer

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AscitesAscites Soft tissue masses or thickening of the Soft tissue masses or thickening of the

parietal peritoneumparietal peritoneum Omental thickening (omental cake)Omental thickening (omental cake) Tumor nodules & enlarged LNs in the Tumor nodules & enlarged LNs in the

mesentery mesentery Thickening & nodularity of the bowel wallThickening & nodularity of the bowel wall

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Anatomy of peritoneumAnatomy of peritoneum

From: http://www.bala6y.org/vb/showthread.php?t=11687

3131Abdom Imaging (2009) 34: 391-402

Pathways of ascites & sites of Pathways of ascites & sites of tumor seedingtumor seeding

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Bil. Ovarian cancer with peritoneal seedingBil. Ovarian cancer with peritoneal seeding

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Peritoneal seeding to paracolic gutters & Peritoneal seeding to paracolic gutters & greater omentumgreater omentum

Paracolic gutter

Paracolic gutter

Omental thickening

Omental thickening

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Peritoneal seeding to Morison’s pouchPeritoneal seeding to Morison’s pouch

Morison’s pouch

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Peritoneal seeding to falciform ligmentPeritoneal seeding to falciform ligment

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Peritoneal seeding to Peritoneal seeding to subdiaphragmatic surfacesubdiaphragmatic surface

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Rectal cancer with abdominal wall and Rectal cancer with abdominal wall and bowel loop involvementbowel loop involvement

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Mesenteric neoplatic implants Mesenteric neoplatic implants with bowel loop involvementwith bowel loop involvement

Abdom Imaging (2009) 34: 391-402

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Mesenteric neoplastic noduleMesenteric neoplastic nodule

Abdom Imaging (2009) 34: 391-402

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Perirectal ovarian carcinoma Perirectal ovarian carcinoma neoplastic implantsneoplastic implants

Abdom Imaging (2009) 34: 391-402

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Ovarian carcinoma-Ovarian carcinoma-cystic peritoneal neoplastic implantcystic peritoneal neoplastic implant

Abdom Imaging (2009) 34: 391-402

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Neoplastic nodule in the adipose Neoplastic nodule in the adipose tissue of the hernia sactissue of the hernia sac

Abdom Imaging (2009) 34: 391-402

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FDG-PET/CT in peritoneal FDG-PET/CT in peritoneal carcinomatosiscarcinomatosis

False negative:False negative: Cystic lesionsCystic lesions Small volume disease or miliaric seedingSmall volume disease or miliaric seeding

False postive:False postive: Bowel activity Bowel activity Focal retained activity in ureters and urinary Focal retained activity in ureters and urinary

bladderbladder

Abdom Imaging (2009) 34: 391-402

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D.D.:D.D.: LymphomaLymphoma Primary peritoneal mesotheliomaPrimary peritoneal mesothelioma Gastrointestinal stromal tumorsGastrointestinal stromal tumors Peritoneal tuberculosisPeritoneal tuberculosis

Indian J Radiol Imaging 2010;20:58-62

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Normal-sized ovarian carcinoma Normal-sized ovarian carcinoma syndromesyndrome

Diffuse metastatic disease of the Diffuse metastatic disease of the peritoneal cavity. peritoneal cavity.

Ovaries are Ovaries are macroscopically normalmacroscopically normal (<4cm)(<4cm) or only have or only have fine nodularitiesfine nodularities on on the external surface.the external surface.

Obstet Gynecol. 1989;73(5 Pt 1):786-92.

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Normal-sized ovarian carcinoma Normal-sized ovarian carcinoma syndromesyndrome

Including:Including: MesotheliomaMesothelioma Primary peritoneal carcinomaPrimary peritoneal carcinoma Primary ovarian carcinoma ( Serous Primary ovarian carcinoma ( Serous surface surface

papillary carcinoma of ovary, papillary carcinoma of ovary, Papillary serous carcinoma in ovaries of normal size ))

Metastatic tumor from another primary originMetastatic tumor from another primary origin

Obstet Gynecol. 1989;73(5 Pt 1):786-92.

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Serous Serous surface surface papillary papillary carcinoma of ovarycarcinoma of ovary

Originating from the Originating from the surface epitheliumsurface epithelium of of the ovarythe ovary

Absence of involvement or only Absence of involvement or only microscopic involvementmicroscopic involvement of the ovarian of the ovarian parenchymaparenchyma..

A distinct subtype of A distinct subtype of serous papillary serous papillary carcinoma of the ovarycarcinoma of the ovary

Extensive peritoneal spreadExtensive peritoneal spread

Acta Radiologica 38 (1997) 847-849

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Imaging findings (CT, US, MRI):Imaging findings (CT, US, MRI): Diffuse nodularitiesDiffuse nodularities along the serosal surface along the serosal surface

of the ovaries, uterus and peritoneum without of the ovaries, uterus and peritoneum without ovarian massovarian mass..

The nodular lesions The nodular lesions obliterated the outer obliterated the outer margin of uterus and ovariesmargin of uterus and ovaries..

Acta Radiologica 38 (1997) 847-849

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nodularity

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AJR 2004;183:1721–1724

Elevated CA-125Elevated CA-125 in all in all pts pts (most > 200 U/ml)(most > 200 U/ml)

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CA-125 & Ovarian CancerCA-125 & Ovarian Cancer

The average reported sensitivities for The average reported sensitivities for ovarian cancer:ovarian cancer: 50% for stage I 50% for stage I 90% for stage II or higher disease90% for stage II or higher disease Varies according to histology Varies according to histology

Specificity of CA 125 is Specificity of CA 125 is limited.limited. Rarely > Rarely > 100~200 U/ml100~200 U/ml in benign in benign

conditions.conditions.

From UpToDate; Epithelial ovarian cancer : Clinical manifestations, diagnostic evaluation, staging, and histopathology

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NotNot a useful diagnostic test in a useful diagnostic test in premenopausalpremenopausal womenwomen, especially at low positive levels , especially at low positive levels (warning if > 200 U/ml). (warning if > 200 U/ml).

It is more useful in It is more useful in postmenopausal womenpostmenopausal women, in , in whom the whom the positive predictive valuepositive predictive value for for malignancy is malignancy is 97 %.97 %.

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High preoperative CA-125 levelsHigh preoperative CA-125 levels correlate correlate with:with: Advanced stage (III or IV)Advanced stage (III or IV) High grade diseaseHigh grade disease Serous histologySerous histology The presence of ascitesThe presence of ascites

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Not a reliable predictor of the likelihood of Not a reliable predictor of the likelihood of optimal cytoreduction. optimal cytoreduction.

Baseline measurementBaseline measurement is useful in is useful in evaluating the success of subsequent evaluating the success of subsequent treatment. treatment.

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CA 125 & Ovarian CancerCA 125 & Ovarian Cancer

A pelvic massA pelvic mass suspicious for malignancy if: suspicious for malignancy if: AscitesAscites Nodularity/fixationNodularity/fixation Evidence of metastasesEvidence of metastases A First degree relative with ovarian or brest A First degree relative with ovarian or brest

cancercancer Elevated CA-125 level (normal < 35)Elevated CA-125 level (normal < 35)

Any abnormal in the postmenopausal Any abnormal in the postmenopausal A level > 200 U/ml in the premenopausal A level > 200 U/ml in the premenopausal

American College of Obstetricians and Gynecologists

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ConclusionConclusion

Peritoneal carcinomatosis occurs commonly with Peritoneal carcinomatosis occurs commonly with abdominopelvic tumors. abdominopelvic tumors.

FDG-PET/CT has the potential to improve FDG-PET/CT has the potential to improve detection of peritoneal carcinomatosis. But there detection of peritoneal carcinomatosis. But there are limits.are limits.

In normal-sized ovarian carcinoma syndrome, In normal-sized ovarian carcinoma syndrome, peritoneal carcinomatosis is noted, despite of peritoneal carcinomatosis is noted, despite of normal size of ovaries.normal size of ovaries.

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ConclusionConclusion

Elevation serum CA-125 ( any abnormal in Elevation serum CA-125 ( any abnormal in the postmenopausal, and > 200 U/ml in the postmenopausal, and > 200 U/ml in the premenopausal) can help in the the premenopausal) can help in the diagnosis of ovarian cancer.diagnosis of ovarian cancer.

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Thank YouThank You

Documents

1 Case presentation 新光醫院 核子醫學科 葉力豪2010/3/13. 2 Case 1: History 70 y/o female 70 y/o female PH: PH: HBV & HCV carrier HBV & HCV carrier DM DM CC: Lower

1 Case presentation 新光醫院核子醫學科葉力豪2010/3/13. 2 Case 1: History 70 y/o female 70 y/o female PH: PH: HBV & HCV carrier HBV & HCV carrier DM DM CC: Lower