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==Overview==
==Overview==


'''Peritoneal carcinomatosis''' (also known as ''peritoneal metastases'') is defined as a malignant tumoral seeding of the peritoneum. Peritoneal carcinomatoses are the most common peritoneal malignancy, these commonly arise from [[ovarian cancer]], [[colon cancer]], [[gastric cancer]], and [[pancreatic cancer]].  Calcified peritoneal carcinomatosis may occur in serous ovarian adenocarcinoma, colon cancer, and gastric cancer. Peritoneal carcinogenesis arises from the celomic epithelium lining of the [[abdominal cavity]] (peritoneum) in response to an oncogenic stimulus.<ref name="pmid10228488">{{cite journal |vauthors=Deraco M, Santoro N, Carraro O, Inglese MG, Rebuffoni G, Guadagni S, Somers DC, Vaglini M |title=Peritoneal carcinomatosis: feature of dissemination. A review |journal=Tumori |volume=85 |issue=1 |pages=1–5 |year=1999 |pmid=10228488 |doi= |url=}}</ref> Common causes of peritoneal carcinomatosis, include: [[Peritoneal mesothelioma|peritoneal mesothelioma,]] [[Colon cancer|colon cancer,]] [[gastric cancer]], and [[pancreatic cancer]]. Early clinical features include [[abdominal pain]], [[abdominal distension]], and [[nausea]]. If left untreated, the majority of patients with peritoneal carcinomatosis may progress to develop [[portal hypertension]], [[pulmonary edema]], and death. Common complications of peritoneal carcinomatosis include [[intestinal obstruction]] and [[Pulmonary embolism|pulmonary thromboembolism]]. The diagnosis of peritoneal carcinomatosis, include: imaging findings compatible with peritoneal carcinomatosis, elevated protein concentration (more than 4.0 g/dL) in ascitic fluid, abnormal [[serum-ascites albumin gradient]] (less than 1.1 g/dL) in ascitic fluid, and high cell count (lymphocyte predominance). The mainstay medical therapy for peritoneal carcinomatosis is hyperthermic intraperitoneal chemotherapy (HIPEC), followed by cytoreductive surgery, [[laparotomy]] in conjunction with cytology testing is the most common approach for the treatment of peritoneal carcinomatosis. Prognosis is generally poor, and the 5-year survival rate of patients with peritoneal carcinomatosis is approximately.
'''Peritoneal carcinomatosis''' (also known as ''peritoneal metastases'') is defined as a malignant tumor of the peritoneum. Metastases are the most common peritoneal malignancy, commonly metastasize from [[ovarian cancer]], [[colon cancer]], [[gastric cancer]], and [[pancreatic cancer]].  Calcified peritoneal carcinomatosis may occur in serous ovarian adenocarcinoma, colon cancer, and gastric cancer. Peritoneal carcinogenesis arises from the celomic epithelium lining of the [[abdominal cavity]] (peritoneum) in response to an oncogenic stimulus. Common causes of peritoneal carcinomatosis, include: [[Peritoneal mesothelioma|peritoneal mesothelioma,]] [[Colon cancer|colon cancer,]] [[gastric cancer]], and [[pancreatic cancer]]. Early clinical features include [[abdominal pain]], [[abdominal distension]], and [[nausea]]. If left untreated, the majority of patients with peritoneal carcinomatosis may progress to develop [[portal hypertension]], [[pulmonary edema]], and death. Common complications of peritoneal carcinomatosis include [[intestinal obstruction]] and [[Pulmonary embolism|pulmonary thromboembolism]]. The diagnosis of peritoneal carcinomatosis, include: Imaging findings compatible with peritoneal carcinomatosis, elevated protein concentration (more than 4.0 g/dL) in ascitic fluid, abnormal [[serum-ascites albumin gradient]] (less than 1.1 g/dL) in ascitic fluid, and high cell count (lymphocyte predominance). The mainstay medical therapy for peritoneal carcinomatosis is hyperthermic intraperitoneal chemotherapy (HIPEC), followed by cytoreductive surgery, [[laparotomy]] in conjunction with cytology testing is the most common approach for the treatment of peritoneal carcinomatosis. Prognosis is generally poor, and the 5-year survival rate of patients with peritoneal carcinomatosis is approximately 20%.


==Historical Perspective==
==Historical Perspective==
*Peritoneal carcinomatosis was first described by Swerdlow in 1959.<ref name="PPP">Swerdlow M: Mesothelioma of the pelvic peritoneum resembling papillary cystadenocarcinoma of the ovary: Case report. Am J Obstet Gynecol 77:200, 1959.</ref>
* Peritoneal carcinomatosis was first described by Swerdlow in 1959.<ref name="PPP">Swerdlow M: Mesothelioma of the pelvic peritoneum resembling papillary cystadenocarcinoma of the ovary: Case report. Am J Obstet Gynecol 77:200, 1959.</ref>


==Classification==
==Classification==
*According to the Gilly classification, peritoneal carcinomatosis may be classified according to nodule size and intraperitoneal involvement (localized or diffuse) into 4 categories:<ref name="pmid20424420">{{cite journal |vauthors=Kianmanesh R, Ruszniewski P, Rindi G, Kwekkeboom D, Pape UF, Kulke M, Sevilla Garcia I, Scoazec JY, Nilsson O, Fazio N, Lesurtel M, Chen YJ, Eriksson B, Cioppi F, O'Toole D |title=ENETS consensus guidelines for the management of peritoneal carcinomatosis from neuroendocrine tumors |journal=Neuroendocrinology |volume=91 |issue=4 |pages=333–40 |year=2010 |pmid=20424420 |doi=10.1159/000286700 |url=}}</ref>
According to the Gilly classification, peritoneal carcinomatosis may be classified according to nodule size and intraperitoneal involvement (localized or diffuse) into 4 categories:<ref name="pmid20424420">{{cite journal |vauthors=Kianmanesh R, Ruszniewski P, Rindi G, Kwekkeboom D, Pape UF, Kulke M, Sevilla Garcia I, Scoazec JY, Nilsson O, Fazio N, Lesurtel M, Chen YJ, Eriksson B, Cioppi F, O'Toole D |title=ENETS consensus guidelines for the management of peritoneal carcinomatosis from neuroendocrine tumors |journal=Neuroendocrinology |volume=91 |issue=4 |pages=333–40 |year=2010 |pmid=20424420 |doi=10.1159/000286700 |url=}}</ref>
:*0 No macroscopic disease
*0 - No macroscopic disease
:*1 Malignant granulations less than 5 mm in diameter localized in one part of the abdomen
*1 - Malignant granulations less than 5 mm in diameter localized in one part of the abdomen
:*2 Malignant granulations less than 5 mm in diameter diffuse to the whole abdomen
*2 - Malignant granulations less than 5 mm in diameter diffuse to the whole abdomen
:*3 Localized or diffuse malignant granulations 5–20 mm in diameter
*3 - Localized or diffuse malignant granulations 5–20 mm in diameter
:*4 Localized or diffuse large malignant masses (more than 2 cm in diameter)
*4 - Localized or diffuse large malignant masses (more than 2 cm in diameter)


==Pathophysiology==
==Pathophysiology==
*The pathogenesis of peritoneal carcinomatosis is characterized by the malignant seeding of a tumor in the peritoneal cavity.<ref name="pmid10228488">{{cite journal |vauthors=Deraco M, Santoro N, Carraro O, Inglese MG, Rebuffoni G, Guadagni S, Somers DC, Vaglini M |title=Peritoneal carcinomatosis: feature of dissemination. A review |journal=Tumori |volume=85 |issue=1 |pages=1–5 |year=1999 |pmid=10228488 |doi= |url=}}</ref>
*The pathogenesis of peritoneal carcinomatosis is characterized by the malignant seeding of a tumor in the peritoneal cavity.<ref name="pmid10228488">{{cite journal |vauthors=Deraco M, Santoro N, Carraro O, Inglese MG, Rebuffoni G, Guadagni S, Somers DC, Vaglini M |title=Peritoneal carcinomatosis: feature of dissemination. A review |journal=Tumori |volume=85 |issue=1 |pages=1–5 |year=1999 |pmid=10228488 |doi= |url=}}</ref>
*Peritoneal carcinogenesis arises from the celomic epithelium lining of the [[abdominal cavity]] (peritoneum) in response to an oncogenic stimulus.<ref name="pmid10228488">{{cite journal |vauthors=Deraco M, Santoro N, Carraro O, Inglese MG, Rebuffoni G, Guadagni S, Somers DC, Vaglini M |title=Peritoneal carcinomatosis: feature of dissemination. A review |journal=Tumori |volume=85 |issue=1 |pages=1–5 |year=1999 |pmid=10228488 |doi= |url=}}</ref>
* Peritoneal carcinogenesis arises from the celomic epithelium lining of the [[abdominal cavity]] (peritoneum) in response to an oncogenic stimulus.<ref name="pmid10228488">{{cite journal |vauthors=Deraco M, Santoro N, Carraro O, Inglese MG, Rebuffoni G, Guadagni S, Somers DC, Vaglini M |title=Peritoneal carcinomatosis: feature of dissemination. A review |journal=Tumori |volume=85 |issue=1 |pages=1–5 |year=1999 |pmid=10228488 |doi= |url=}}</ref>
*The mutation on [[BRCA|BRCA1/BRCA2]]  has been associated with the development of peritoneal carcinomatosis.
* The mutation on [[BRCA|BRCA1/BRCA2]]  has been associated with the development of peritoneal carcinomatosis.
*On gross pathology, characteristic findings of peritoneal carcinomatosis, include:<ref name="wiki">Peritoneum. Libre patholgy.  https://librepathology.org/wiki/Peritoneum  Accessed on April 7, 2016</ref>
* On gross pathology, characteristic findings of peritoneal carcinomatosis, include:<ref name="wiki">Peritoneum. Libre patholgy.  https://librepathology.org/wiki/Peritoneum  Accessed on April 7, 2016</ref>
:*Multilocular thin-walled cysts containing serous fluid  
** Multilocular thin-walled cysts containing serous fluid  
:*Occasionally unilocular
** Occasionally unilocular
:*May be up to 15 cm
** May be up to 15 cm
:*Adherent to the surface
** Adherent to the surface
*On microscopic histopathological analysis, characteristic findings of peritoneal carcinomatosis, include:<ref name="wiki">Peritoneum. Libre patholgy.  https://librepathology.org/wiki/Peritoneum  Accessed on April 7, 2016</ref>
* On microscopic histopathological analysis, characteristic findings of peritoneal carcinomatosis, include:<ref name="wiki">Peritoneum. Libre patholgy.  https://librepathology.org/wiki/Peritoneum  Accessed on April 7, 2016</ref>
:*Thin-walled, irregular-shaped cysts  
** Thin-walled, irregular-shaped cysts  
:*Mesothelial lining
** Mesothelial lining
:*[[Squamous metaplasia]]
**[[Squamous metaplasia]]
:*Eosinophilic fluid
** Eosinophilic fluid


==Causes==
==Causes==
* Common causes of peritoneal carcinomatosis, include:<ref name="wiki">Peritoneal carcinomatosis. Wikipedia. https://en.wikipedia.org/wiki/Primary_peritoneal_carcinoma Accessed on April 7, 2016</ref>
Common causes of peritoneal carcinomatosis, include:<ref name="wiki">Peritoneal carcinomatosis. Wikipedia. https://en.wikipedia.org/wiki/Primary_peritoneal_carcinoma Accessed on April 7, 2016</ref>
:*[[Peritoneal mesothelioma]]  
*[[Peritoneal mesothelioma]]  
:*[[Colon cancer]]
*[[Colon cancer]]
:*[[Gastric cancer]]
*[[Gastric cancer]]
:*[[Pancreatic cancer]]
*[[Pancreatic cancer]]
* Peritoneal carcinomatosis may also be caused by a mutation in the BCRA1 or BCRA2  genes.
Peritoneal carcinomatosis may also be caused by a mutation in the BCRA1 or BCRA2  genes.


==Differentiating Peritoneal Carcinomatosis from Other Diseases==
==Differentiating Peritoneal Carcinomatosis from Other Diseases==
*Peritoneal carcinomatosis must be differentiated from other diseases that cause abdominal pain, ascites, and weight loss, such as:<ref name="wiki">Peritoneal metastases. Dr Henry Knipe.  Radiopedia http://radiopaedia.org/articles/peritoneal-metastases Accessed on April 7, 2016</ref>
Peritoneal carcinomatosis must be differentiated from other diseases that cause abdominal pain, ascites, and weight loss, such as:<ref name="wiki">Peritoneal metastases. Dr Henry Knipe.  Radiopedia http://radiopaedia.org/articles/peritoneal-metastases Accessed on April 7, 2016</ref>
:*[[Peritoneal mesothelioma]]  
* [[Peritoneal mesothelioma]]  
:*[[Tuberculosis|Peritoneal tuberculosis]]
* [[Tuberculosis|Peritoneal tuberculosis]]
:*[[Pseudomyxoma peritonei]]
* [[Pseudomyxoma peritonei]]
* [[Spontaneous bacterial peritonitis|Spontaneous bacterial peritonitis (SBP)]]
* [[Secondary bacterial peritonitis]]
 
{| style="margin: 1em 1em 1em 0; background: #f9f9f9; border: 1px #aaa solid; border-collapse: collapse;" cellspacing="0" cellpadding="4" border="2"
|+'''Differentiating peritoneal carcinomatosis from other diseases'''
! colspan="2" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF| '''Disease'''}}
! colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF| '''Prominent clinical findings'''}}
! colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF| '''Lab tests'''}}
! colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF| '''Tratment'''}}
|-
! rowspan="3" |'''Primary peritonitis'''
!'''[[Primary peritonitis|Spontaneous bacterial peritonitis]]'''
|
* Absence of GI [[perforation]], most closely associated with [[cirrhosis]] and [[Liver disease|advanced liver disease]].
* Presents with abrupt onset of [[fever]], [[abdominal pain]], [[distension]], and [[rebound tenderness]].
|
* Most have clinical and biochemical manifestations of advanced [[cirrhosis]] or [[nephrosis]] like [[leukocytosis]],[[hypoalbuminemia]].
* Prolonged [[prothrombin]] time. SAAG >1.1 g/dL, increased serum [[lactic acid]] level, or a decreased [[Ascites|ascitic fluid]] pH (< 7.31) supports the diagnosis. [[Gram staining]] reveals bacteria in only 25% of cases.
* Diagnosed by analysis of the [[Ascitic|ascitic fluid]] which reveals [[WBC]] > 500/ML, and [[PMN]] >250cells/ml.
* [[Culture medium|Culture]] of ascitic fluid inoculated immediately into [[blood culture]] media at the bedside usually reveals a single [[Enteric Bacilli|enteric organism]], most commonly ''[[Escherichia coli]]'', ''[[Klebsiella]]'', or [[streptococci]].
|
* Once diagnosed, it is treated with [[Ceftriaxone]].
|-
!'''[[Tuberculous peritonitis]]'''
|
* Seen in 0.5% of new cases of [[tuberculosis]] particularly in young women in endemic areas as a primary infection.
* Presents with [[abdominal pain]] and [[distension]], [[fever]], [[night sweats]], [[weight loss]], and altered bowel habits.
|
* [[Ascites]] is present in about half of cases. [[Abdominal mass]] may be felt in a third of cases. The [[peritoneal fluid]] is characterized by a [[protein]] concentration > 3 g/dL with < 1.1 g/dL SAAG and [[Lymphocyte|lymphocyte predominance]] of [[WBC]].
* Definitive diagnosis in 80% of cases is by culture. Most patients presenting acutely are diagnosed only by [[laparotomy]].
|
* Combination [[Antituberculosis|antituberculosis chemotherapy]] is preferred in chronic cases.
|-
!'''[[Continuous ambulatory peritoneal dialysis|Continuous Ambulatory Peritoneal Dialysis]]''' [[Continuous ambulatory peritoneal dialysis|('''CAPD peritonitis)''']]
|
* [[Peritonitis]] is one of the major complications of [[peritoneal dialysis]] & 72.6% occurred within the first six months of [[peritoneal dialysis]].
* Historically, [[coagulase-negative staphylococci]] were the most common cause of peritonitis in [[Continuous ambulatory peritoneal dialysis|CAPD]], presumably due to touch contamination or infection via the pericatheter route.
* Treatment for [[peritoneal dialysis]]-associated peritonitis consists of [[Antimicrobial drug|antimicrobial therapy]], in some cases catheter removal is also warranted.
* Additional therapies for [[Peritonitis|relapsing or recurrent peritonitis]] may include [[Fibrinolytic agent|fibrinolytic agents]] and [[peritoneal lavage]]. Most episodes of peritoneal dialysis-associated peritonitis resolve with outpatient [[Antibiotic|antibiotic treatment]].
|
* Majority of [[peritonitis]] cases are caused by [[bacteria]] (50%-due to [[Gram-positive bacteria|gram positive]] organisms, 15% to [[gram negative]] organisms, 20% were culture negative. 2% of cases are caused by [[fungi]], mostly [[Candida]] species. Polymicrobial infection in 4%. Exit-site infection was present in 13% and a [[peritoneal fluid]] leak in 3 % and [[M.tuberculosis]] 0.1%.
|
* [[Antibiotic|Initial empiric antibiotic coverage]] for peritoneal dialysis-associated peritonitis consists of coverage for [[gram-positive]] organisms (by [[vancomycin]] or a [[Cephalosporins|first-generation cephalosporin]]) and [[gram-negative]] organisms (by a [[cephalosporin|third-generation cephalosporin]] or an [[aminoglycoside]]). Subsequently, the regimen should be adjusted based on [[Culture medium|culture]] and [[sensitivity]] data. Cure rates are approximately 75%.
|-
! rowspan="2" |'''[[Secondary peritonitis]]'''
!'''Acute [[bacterial]] [[secondary peritonitis]]'''
|
* Occurs after perforating, penetrating, inflammatory, infectious, or [[ischemic]] injuries of the GI or GU tracts. Most often follows disruption of a hollow viscera, chemical peritonitis, bacterial peritonitis (polymicrobial, includes [[aerobic]] [[gram negative|gram negatives]] {[[E coli]], [[Klebsiella]], [[Enterobacter]], [[Proteus mirabilis]]} and gram positives { [[Enterococcus]], [[Streptococcus]]} and [[anaerobes]] {[[Bacteroides]], [[clostridia]]}).
* Presents with [[abdominal pain]], [[tenderness]], [[guarding]] or rigidity, [[distension]], free peritoneal air, and diminished [[bowel sounds]]. Signs that reflect irritation of the parietal peritoneum resulting [[ileus]]. Systemic findings include [[fever]], [[chills]] or [[rigors]], [[tachycardia]], [[sweating]], [[tachypnea]], [[restlessness]], [[dehydration]], [[oliguria]], [[disorientation]], and, ultimately, refractory [[shock]].
| rowspan="2" |
| rowspan="2" |
* [[Peritoneal lavage]], [[Laparoscopy]] are the treatment of choice.
|-
!'''[[Biliary]] [[Secondary peritonitis|peritonitis]]'''
|
* Most often seen in cases of rupture of pathological [[gallbladder]] or [[bile duct]] or [[Cholangitis|cholangitic abscess]] or secondary to obstruction of  the [[biliary tract]].
* Seen in alcoholic patients with [[ascites]].
|-
! colspan="2" |'''[[Peritonitis|Tertiary peritonitis]]'''
|
* Persistence or recurrence of [[Infection|intraabdominal infection]] following apparently adequate therapy of [[Peritonitis|primary or secondary peritonitis]].
* Associated with [[Mortality|high mortality]] due to multi organ dysfunction. It presents in a similar way as other [[peritonitis]] but is recognized as an adverse outcome with poor prognosis.
|
* [[Enterococcus]], [[Candida]], [[Staphylococcus epidermidis]], and [[Enterobacter]] being the most common organisms.
|
* Characterized by lack of response to appropriate surgical and [[antibiotic therapy]] due to disturbance in the hosts [[immune response]].
|-
! colspan="2" |'''[[Familial mediterranean fever|Familial Mediterranean fever (periodic peritonitis, familial paroxysmal polyserositis)]]'''
|
* Rare [[Genetic disorder|genetic condition]] which affects individuals of Mediterranean genetic background.
* Etiology is unclear.
* Presents with recurrent bouts of [[abdominal pain]] and [[tenderness]] along with [[pleuritic]] or [[joint pain]]. [[Fever]] and [[leukocytosis]] are common.
|
|
* [[Colchicine]] prevents but does not treat acute attacks.
|-
! colspan="2" |'''[[Granulomatous peritonitis]]'''
|
* A rare condition caused by disposable surgical fabrics or food particles from a [[perforated ulcer]], eliciting a vigorous [[granulomatous]] ([[Hypersensitivity|delayed hypersensitivity]]) response in some patients 2-6 weeks after [[laparotomy]].
* Presents with [[abdominal pain]], [[fever]], [[nausea and vomiting]], [[ileus]], and systemic complaints, mild and diffuse [[abdominal tenderness]].
|
* Diagnosed by the demonstration of diagnostic Maltese cross pattern of starch particles.
|
* The disease is self-limiting.
* Treated with [[corticosteroids]] or [[Anti inflammatory medications|anti-inflammatory agents]].
|-
! colspan="2" |'''[[Sclerosing encapsulating peritonitis]]'''
|
* Seen in conditions associated with long term [[peritoneal dialysis]], shunts like [[Ventriculoperitoneal shunt|VP shunts]], history of [[Abdominal surgery|abdominal surgeries]], [[liver transplantation]].
* Symptoms include [[nausea]], [[abdominal pain]], [[diarrhea]], [[anorexia]], bloody [[ascites]].
|
|
|-
! colspan="2" |'''[[Abscess|Intraperitoneal abscesses]]'''
|
* Most common etiologies being [[Perforation|Gastrointestinal perforations]], postoperative complications, and penetrating injuries.
* Signs and symptoms depend on the location of the [[abscess]] within the [[peritoneal cavity]] and the extent of involvement of the surrounding structures.
* Diagnosis is suspected in any patient with a predisposing condition. In a third of cases it occurs as a sequela of [[Peritonitis|generalized peritonitis]].
* The pathogenic organisms are similar to those responsible for [[peritonitis]], but [[anaerobic]] organisms occupy an important role.
* The [[mortality rate]] of serious [[Abscesses|intra-abdominal abscesses]] is about 30%.
|
* Diagnosed best by [[CT-scans|CT]] scan of the abdomen.
|
* Treatment consists of prompt and complete [[CT]] or [[Ultrasound|US]] guided drainage of the [[abscess]], control of the primary cause, and adjunctive use of effective [[Antibiotics|antibiotics.]] Open drainage is reserved for [[abscesses]] for which percutaneous drainage is inappropriate or unsuccessful.
|-
! colspan="2" |'''[[Peritoneal mesothelioma]]'''
|
* Arises from the [[mesothelium]] lining the [[peritoneal cavity]].
* Its incidence is approximately 300-500 new cases being diagnosed in the United States each year.  As with [[pleural mesothelioma]], there is an association with an [[Asbestos|asbestos exposure]].
* Most commonly affects men at the age of 50-69 years. Patients most often present with [[abdominal pain]] and later increased abdominal girth and [[ascites]] along with [[anorexia]], [[weight loss]] and [[abdominal pain]].
* Mean time from diagnosis to death is less than 1 year without treatment. 
|
* [[Computed tomography|CT]] with [[Contrast|intravenous contrast]] typically demonstrates the thickening of the [[peritoneum]]. [[Laparoscopy]] with tissue biopsy or CT guided tissue biopsy with [[immunohistochemical staining]] for [[calretinin]], [[cytokeratin|cytokeratin 5/6]], [[mesothelin]], and [[WT1|Wilms tumor 1 antigen]] remain the [[Gold standard (test)|gold standard]] for diagnosis.
|
* At [[laparotomy]] the goal is cytoreduction with [[excision]]. Debulking surgery and intraperitoneal [[chemotherapy]] improves survival in some cases.
|-
! colspan="2" |'''[[peritoneal carcinomatosis]]'''
|
* Associated with a history of [[ovarian]] or [[Malignancy|GI tract malignancy]].
* Symptoms include [[ascites]], [[abdominal pain]], [[nausea]], [[vomiting]].
|
|
|}


==Epidemiology and Demographics==
==Epidemiology and Demographics==
* The prevalence of peritoneal carcinomatosis is approximately 0.03 per 100,000 individuals worldwide.<ref name="pmid22287157">{{cite journal |vauthors=Segelman J, Granath F, Holm T, Machado M, Mahteme H, Martling A |title=Incidence, prevalence and risk factors for peritoneal carcinomatosis from colorectal cancer |journal=Br J Surg |volume=99 |issue=5 |pages=699–705 |year=2012 |pmid=22287157 |doi=10.1002/bjs.8679 |url=}}</ref>
* The prevalence of peritoneal carcinomatosis is approximately 0.03 per 100,000 individuals worldwide.<ref name="pmid22287157">{{cite journal |vauthors=Segelman J, Granath F, Holm T, Machado M, Mahteme H, Martling A |title=Incidence, prevalence and risk factors for peritoneal carcinomatosis from colorectal cancer |journal=Br J Surg |volume=99 |issue=5 |pages=699–705 |year=2012 |pmid=22287157 |doi=10.1002/bjs.8679 |url=}}</ref>
===Age===
===Age===
*Peritoneal carcinomatosis is more commonly observed among patients aged 50 - 70 years.<ref name="pmid8519536">{{cite journal |vauthors=Villanueva A, Pérez C, Sabaté JM, Llauger J, Giménez A, Sanchis E, García T, Moreno A |title=[Peritoneal carcinomatosis. Review of CT findings in 107 cases] |language=Spanish; Castilian |journal=Rev Esp Enferm Dig |volume=87 |issue=10 |pages=707–14 |year=1995 |pmid=8519536 |doi= |url=}}</ref>
* Peritoneal carcinomatosis is more commonly observed among patients aged 50 - 70 years.<ref name="pmid8519536">{{cite journal |vauthors=Villanueva A, Pérez C, Sabaté JM, Llauger J, Giménez A, Sanchis E, García T, Moreno A |title=[Peritoneal carcinomatosis. Review of CT findings in 107 cases] |language=Spanish; Castilian |journal=Rev Esp Enferm Dig |volume=87 |issue=10 |pages=707–14 |year=1995 |pmid=8519536 |doi= |url=}}</ref>
*Peritoneal carcinomatosis is more commonly observed among adults.<ref name="pmid21160812">{{cite journal |vauthors=Kusamura S, Baratti D, Zaffaroni N, Villa R, Laterza B, Balestra MR, Deraco M |title=Pathophysiology and biology of peritoneal carcinomatosis |journal=World J Gastrointest Oncol |volume=2 |issue=1 |pages=12–8 |year=2010 |pmid=21160812 |pmc=2999153 |doi=10.4251/wjgo.v2.i1.12 |url=}}</ref>
* Peritoneal carcinomatosis is more commonly observed among adults.<ref name="pmid21160812">{{cite journal |vauthors=Kusamura S, Baratti D, Zaffaroni N, Villa R, Laterza B, Balestra MR, Deraco M |title=Pathophysiology and biology of peritoneal carcinomatosis |journal=World J Gastrointest Oncol |volume=2 |issue=1 |pages=12–8 |year=2010 |pmid=21160812 |pmc=2999153 |doi=10.4251/wjgo.v2.i1.12 |url=}}</ref>
===Gender===
===Gender===
*Females are more commonly affected with peritoneal carcinomatosis than males.<ref name="pmid21160812">{{cite journal |vauthors=Kusamura S, Baratti D, Zaffaroni N, Villa R, Laterza B, Balestra MR, Deraco M |title=Pathophysiology and biology of peritoneal carcinomatosis |journal=World J Gastrointest Oncol |volume=2 |issue=1 |pages=12–8 |year=2010 |pmid=21160812 |pmc=2999153 |doi=10.4251/wjgo.v2.i1.12 |url=}}</ref>
* Females are more commonly affected with peritoneal carcinomatosis than males.<ref name="pmid21160812">{{cite journal |vauthors=Kusamura S, Baratti D, Zaffaroni N, Villa R, Laterza B, Balestra MR, Deraco M |title=Pathophysiology and biology of peritoneal carcinomatosis |journal=World J Gastrointest Oncol |volume=2 |issue=1 |pages=12–8 |year=2010 |pmid=21160812 |pmc=2999153 |doi=10.4251/wjgo.v2.i1.12 |url=}}</ref>
===Race===
===Race===
*There is no racial predilection for peritoneal carcinomatosis.<ref name="pmid21160812">{{cite journal |vauthors=Kusamura S, Baratti D, Zaffaroni N, Villa R, Laterza B, Balestra MR, Deraco M |title=Pathophysiology and biology of peritoneal carcinomatosis |journal=World J Gastrointest Oncol |volume=2 |issue=1 |pages=12–8 |year=2010 |pmid=21160812 |pmc=2999153 |doi=10.4251/wjgo.v2.i1.12 |url=}}</ref>
* There is no racial predilection for peritoneal carcinomatosis.<ref name="pmid21160812">{{cite journal |vauthors=Kusamura S, Baratti D, Zaffaroni N, Villa R, Laterza B, Balestra MR, Deraco M |title=Pathophysiology and biology of peritoneal carcinomatosis |journal=World J Gastrointest Oncol |volume=2 |issue=1 |pages=12–8 |year=2010 |pmid=21160812 |pmc=2999153 |doi=10.4251/wjgo.v2.i1.12 |url=}}</ref>


==Risk Factors==
==Risk Factors==
*The most important  risk factor in the development of peritoneal carcinomatosis is the presence of [[ovarian cancer]], [[colon cancer]], [[gastric cancer]], and [[pancreatic cancer]].
The most important  risk factor in the development of peritoneal carcinomatosis include:
* [[Ovarian cancer]]
* [[Colon cancer]]
* [[Gastric cancer]]
* [[Pancreatic cancer]]
 
== Natural History, Complications and Prognosis==
== Natural History, Complications and Prognosis==
*The majority of patients with peritoneal carcinomatosis may be initially [[asymptomatic]].  
*The majority of patients with peritoneal carcinomatosis may be initially [[asymptomatic]].  
Line 67: Line 194:
*If left untreated, the majority of patients with peritoneal carcinomatosis may progress to develop [[portal hypertension]], [[pulmonary edema]], and death.  
*If left untreated, the majority of patients with peritoneal carcinomatosis may progress to develop [[portal hypertension]], [[pulmonary edema]], and death.  
*Common complications of peritoneal carcinomatosis include [[intestinal obstruction]] and [[Pulmonary embolism|pulmonary thromboembolism]].
*Common complications of peritoneal carcinomatosis include [[intestinal obstruction]] and [[Pulmonary embolism|pulmonary thromboembolism]].
*Prognosis is generally poor, and the 5 year survival rate of patients with peritoneal carcinomatosis is approximately.
*Prognosis is generally poor, and the 5 year survival rate of patients with peritoneal carcinomatosis is approximately 20%.<ref name="pmid24201391">{{cite journal |vauthors=Thomassen I, van Gestel YR, Lemmens VE, de Hingh IH |title=Incidence, prognosis, and treatment options for patients with synchronous peritoneal carcinomatosis and liver metastases from colorectal origin |journal=Dis. Colon Rectum |volume=56 |issue=12 |pages=1373–80 |year=2013 |pmid=24201391 |doi=10.1097/DCR.0b013e3182a62d9d |url=}}</ref><ref name="pmid10228488">{{cite journal |vauthors=Deraco M, Santoro N, Carraro O, Inglese MG, Rebuffoni G, Guadagni S, Somers DC, Vaglini M |title=Peritoneal carcinomatosis: feature of dissemination. A review |journal=Tumori |volume=85 |issue=1 |pages=1–5 |year=1999 |pmid=10228488 |doi= |url=}}</ref>


== Diagnosis ==
== Diagnosis ==
===Diagnostic Criteria===
===Diagnostic Criteria===
*The diagnosis of peritoneal carcinomatosis is made when at least the following diagnostic criteria are met:<ref name="pmid8519536">{{cite journal |vauthors=Villanueva A, Pérez C, Sabaté JM, Llauger J, Giménez A, Sanchis E, García T, Moreno A |title=[Peritoneal carcinomatosis. Review of CT findings in 107 cases] |language=Spanish; Castilian |journal=Rev Esp Enferm Dig |volume=87 |issue=10 |pages=707–14 |year=1995 |pmid=8519536 |doi= |url=}}</ref>
The diagnosis of peritoneal carcinomatosis is made when at least the following diagnostic criteria are met:<ref name="pmid8519536">{{cite journal |vauthors=Villanueva A, Pérez C, Sabaté JM, Llauger J, Giménez A, Sanchis E, García T, Moreno A |title=[Peritoneal carcinomatosis. Review of CT findings in 107 cases] |language=Spanish; Castilian |journal=Rev Esp Enferm Dig |volume=87 |issue=10 |pages=707–14 |year=1995 |pmid=8519536 |doi= |url=}}</ref>
:*Imaging findings compatible with peritoneal carcinomatosis (see below)  
:*Imaging findings compatible with peritoneal carcinomatosis (see below)  
:*Elevated protein concentration (more than 4.0 g/dL)
:*Elevated protein concentration (more than 4.0 g/dL)
Line 79: Line 206:
=== Symptoms ===
=== Symptoms ===
*Peritoneal carcinomatosis is usually asymptomatic.
*Peritoneal carcinomatosis is usually asymptomatic.
*Symptoms of peritoneal carcinomatosis may include the following:
*Symptoms of peritoneal carcinomatosis may include the following:<ref name="wiki">Peritoneal carcinomatosis. Wikipedia. https://en.wikipedia.org/wiki/Primary_peritoneal_carcinoma Accessed on April 7, 2016</ref>
:*[[Abdominal distension]]
:*[[Abdominal distension]]
:*[[Nausea]]
:*[[Nausea]]
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=== Physical Examination ===
=== Physical Examination ===
*Patients with peritoneal carcinomatosis usually appear pale and lethargic.
*Patients with peritoneal carcinomatosis usually appear pale and lethargic.
*Physical examination may be remarkable for:
*Physical examination may be remarkable for:<ref name="wiki">Peritoneal carcinomatosis. Wikipedia. https://en.wikipedia.org/wiki/Primary_peritoneal_carcinoma Accessed on April 7, 2016</ref>
'''Inspection'''
'''Inspection'''
:* Enlarged abdomen  
:* Enlarged abdomen  
Line 102: Line 229:


=== Laboratory Findings ===
=== Laboratory Findings ===
*Laboratory findings consistent with the diagnosis of peritoneal carcinomatosis, include:
*Laboratory findings consistent with the diagnosis of peritoneal carcinomatosis, include:<ref name="pmid21160812">{{cite journal |vauthors=Kusamura S, Baratti D, Zaffaroni N, Villa R, Laterza B, Balestra MR, Deraco M |title=Pathophysiology and biology of peritoneal carcinomatosis |journal=World J Gastrointest Oncol |volume=2 |issue=1 |pages=12–8 |year=2010 |pmid=21160812 |pmc=2999153 |doi=10.4251/wjgo.v2.i1.12 |url=}}</ref>
:* Elevated [[carcinoembryonic antigen]] (unspecific)  
:* Elevated [[carcinoembryonic antigen]] (unspecific)  
:* Elevated [[CA125|cancer antigen 125]] (unspecific)
:* Elevated [[CA125|cancer antigen 125]] (unspecific)
Line 110: Line 237:
*[[CT scan|Enhanced CT scan]] is the imaging modality of choice for peritoneal carcinomatosis.<ref name="pmid8519536">{{cite journal |vauthors=Villanueva A, Pérez C, Sabaté JM, Llauger J, Giménez A, Sanchis E, García T, Moreno A |title=[Peritoneal carcinomatosis. Review of CT findings in 107 cases] |language=Spanish; Castilian |journal=Rev Esp Enferm Dig |volume=87 |issue=10 |pages=707–14 |year=1995 |pmid=8519536 |doi= |url=}}</ref>
*[[CT scan|Enhanced CT scan]] is the imaging modality of choice for peritoneal carcinomatosis.<ref name="pmid8519536">{{cite journal |vauthors=Villanueva A, Pérez C, Sabaté JM, Llauger J, Giménez A, Sanchis E, García T, Moreno A |title=[Peritoneal carcinomatosis. Review of CT findings in 107 cases] |language=Spanish; Castilian |journal=Rev Esp Enferm Dig |volume=87 |issue=10 |pages=707–14 |year=1995 |pmid=8519536 |doi= |url=}}</ref>
*On CT, peritoneal carcinomatosis is characterized by the following findings:<ref name="wiki">Peritoneal metastases. Dr Henry Knipe.  Radiopedia http://radiopaedia.org/articles/peritoneal-metastases Accessed on April 7, 2016</ref>
*On CT, peritoneal carcinomatosis is characterized by the following findings:<ref name="wiki">Peritoneal metastases. Dr Henry Knipe.  Radiopedia http://radiopaedia.org/articles/peritoneal-metastases Accessed on April 7, 2016</ref>
:* Smooth or nodular peritoneal thickening and enhancement.
:* Smooth or nodular [[Peritoneum|peritoneal]] thickening and enhancement.
:* Implants on the liver and the splenic surfaces are frequently seen and result in scalloping of the surface by the masses.
:* Implants on the liver and the splenic surfaces are frequently seen and result in scalloping of the surface by the masses.
:* Sites of tumor implantation are the intersegmental fissure, superior recess of the lesser sac, subphrenic space, and Morison pouch.
:* Sites of tumor implantation are the intersegmental fissure, superior recess of the lesser sac, subphrenic space, and Morison pouch.
:* Usually there is large ascites, which is often loculated.
:* Usually there is large [[ascites]], which is often loculated.
*The images below demonstrate a case of peritoneal carcinomatosis.
*The images below demonstrate a case of peritoneal carcinomatosis.
<gallery>
Image:
Carcinomatosis-001.jpg
Image:
Carcinomatosis-002.jpg
Image:
Carcinomatosis-003.jpg
</gallery>
=== Other Diagnostic Studies ===
=== Other Diagnostic Studies ===
*Peritoneal carcinomatosis may also be diagnosed using abdominal paracentesis.  
*Peritoneal carcinomatosis may also be diagnosed using abdominal paracentesis.  
Line 142: Line 254:
*The mainstay medical therapy for peritoneal carcinomatosis is hyperthermic intraperitoneal chemotherapy (HIPEC).<ref name="pmid19133112">{{cite journal |vauthors=Glockzin G, Schlitt HJ, Piso P |title=Peritoneal carcinomatosis: patients selection, perioperative complications and quality of life related to cytoreductive surgery and hyperthermic intraperitoneal chemotherapy |journal=World J Surg Oncol |volume=7 |issue= |pages=5 |year=2009 |pmid=19133112 |pmc=2639355 |doi=10.1186/1477-7819-7-5 |url=}}</ref>
*The mainstay medical therapy for peritoneal carcinomatosis is hyperthermic intraperitoneal chemotherapy (HIPEC).<ref name="pmid19133112">{{cite journal |vauthors=Glockzin G, Schlitt HJ, Piso P |title=Peritoneal carcinomatosis: patients selection, perioperative complications and quality of life related to cytoreductive surgery and hyperthermic intraperitoneal chemotherapy |journal=World J Surg Oncol |volume=7 |issue= |pages=5 |year=2009 |pmid=19133112 |pmc=2639355 |doi=10.1186/1477-7819-7-5 |url=}}</ref>
*Common chemotherapy agents, include:<ref name="pmid19133112">{{cite journal |vauthors=Glockzin G, Schlitt HJ, Piso P |title=Peritoneal carcinomatosis: patients selection, perioperative complications and quality of life related to cytoreductive surgery and hyperthermic intraperitoneal chemotherapy |journal=World J Surg Oncol |volume=7 |issue= |pages=5 |year=2009 |pmid=19133112 |pmc=2639355 |doi=10.1186/1477-7819-7-5 |url=}}</ref>
*Common chemotherapy agents, include:<ref name="pmid19133112">{{cite journal |vauthors=Glockzin G, Schlitt HJ, Piso P |title=Peritoneal carcinomatosis: patients selection, perioperative complications and quality of life related to cytoreductive surgery and hyperthermic intraperitoneal chemotherapy |journal=World J Surg Oncol |volume=7 |issue= |pages=5 |year=2009 |pmid=19133112 |pmc=2639355 |doi=10.1186/1477-7819-7-5 |url=}}</ref>
:*[[Mitomycin]]  
**[[Mitomycin]]  
:*[[Cisplatin]]
**[[Cisplatin]]
:*[[Oxaliplatin]]
**[[Oxaliplatin]]
:*[[Doxorubicin]]
**[[Doxorubicin]]
:*[[Mitoxantrone]]
**[[Mitoxantrone]]


=== Surgery ===
=== Surgery ===
*Cytoreductive surgery is the mainstay of therapy for peritoneal carcinomatosis.<ref name="pmid19133112">{{cite journal |vauthors=Glockzin G, Schlitt HJ, Piso P |title=Peritoneal carcinomatosis: patients selection, perioperative complications and quality of life related to cytoreductive surgery and hyperthermic intraperitoneal chemotherapy |journal=World J Surg Oncol |volume=7 |issue= |pages=5 |year=2009 |pmid=19133112 |pmc=2639355 |doi=10.1186/1477-7819-7-5 |url=}}</ref>
* Cytoreductive surgery is the mainstay of therapy for peritoneal carcinomatosis.<ref name="pmid19133112">{{cite journal |vauthors=Glockzin G, Schlitt HJ, Piso P |title=Peritoneal carcinomatosis: patients selection, perioperative complications and quality of life related to cytoreductive surgery and hyperthermic intraperitoneal chemotherapy |journal=World J Surg Oncol |volume=7 |issue= |pages=5 |year=2009 |pmid=19133112 |pmc=2639355 |doi=10.1186/1477-7819-7-5 |url=}}</ref>
*[[Laparotomy]] in conjunction with cytology testing is the most common approach to the treatment of peritoneal carcinomatosis.
* [[Laparotomy]] in conjunction with cytology testing is the most common approach to the treatment of peritoneal carcinomatosis.
*Cytoreductive surgery is composed of three steps: exploration of the abdominal cavity, debulking and chemoperfusion.  
* Cytoreductive surgery is composed of three steps: Exploration of the abdominal cavity, debulking and chemoperfusion.  


=== Prevention ===
=== Prevention ===
*There are no primary preventive measures available for peritoneal carcinomatosis.
* There are no primary preventive measures available for peritoneal carcinomatosis.
*Once diagnosed and successfully treated, patients with peritoneal carcinomatosis are followed-up every 1, 3 or 6 months.  
* Once diagnosed and successfully treated, patients with peritoneal carcinomatosis are followed-up every 1, 3 or 6 months.  
*Follow-up testing includes ultrasound, paracentesis, and abdominal examination.<ref name="pmid8519536">{{cite journal |vauthors=Villanueva A, Pérez C, Sabaté JM, Llauger J, Giménez A, Sanchis E, García T, Moreno A |title=[Peritoneal carcinomatosis. Review of CT findings in 107 cases] |language=Spanish; Castilian |journal=Rev Esp Enferm Dig |volume=87 |issue=10 |pages=707–14 |year=1995 |pmid=8519536 |doi= |url=}}</ref>
* Follow-up testing includes [[ultrasound]], [[paracentesis]], and abdominal examination.<ref name="pmid8519536">{{cite journal |vauthors=Villanueva A, Pérez C, Sabaté JM, Llauger J, Giménez A, Sanchis E, García T, Moreno A |title=[Peritoneal carcinomatosis. Review of CT findings in 107 cases] |language=Spanish; Castilian |journal=Rev Esp Enferm Dig |volume=87 |issue=10 |pages=707–14 |year=1995 |pmid=8519536 |doi= |url=}}</ref>


==References==
==References==
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[[Category: Oncology]]
[[Category: Oncology]]
[[Category:Up-To-Date]]
[[Category:Oncology]]
[[Category:Medicine]]
[[Category:Gastroenterology]]
[[Category:Surgery]]

Latest revision as of 17:19, 23 May 2019

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Maria Fernanda Villarreal, M.D. [2]

Synonyms and keywords: Peritoneal metastases; Peritoneal seeding

Overview

Peritoneal carcinomatosis (also known as peritoneal metastases) is defined as a malignant tumor of the peritoneum. Metastases are the most common peritoneal malignancy, commonly metastasize from ovarian cancer, colon cancer, gastric cancer, and pancreatic cancer. Calcified peritoneal carcinomatosis may occur in serous ovarian adenocarcinoma, colon cancer, and gastric cancer. Peritoneal carcinogenesis arises from the celomic epithelium lining of the abdominal cavity (peritoneum) in response to an oncogenic stimulus. Common causes of peritoneal carcinomatosis, include: peritoneal mesothelioma, colon cancer, gastric cancer, and pancreatic cancer. Early clinical features include abdominal pain, abdominal distension, and nausea. If left untreated, the majority of patients with peritoneal carcinomatosis may progress to develop portal hypertension, pulmonary edema, and death. Common complications of peritoneal carcinomatosis include intestinal obstruction and pulmonary thromboembolism. The diagnosis of peritoneal carcinomatosis, include: Imaging findings compatible with peritoneal carcinomatosis, elevated protein concentration (more than 4.0 g/dL) in ascitic fluid, abnormal serum-ascites albumin gradient (less than 1.1 g/dL) in ascitic fluid, and high cell count (lymphocyte predominance). The mainstay medical therapy for peritoneal carcinomatosis is hyperthermic intraperitoneal chemotherapy (HIPEC), followed by cytoreductive surgery, laparotomy in conjunction with cytology testing is the most common approach for the treatment of peritoneal carcinomatosis. Prognosis is generally poor, and the 5-year survival rate of patients with peritoneal carcinomatosis is approximately 20%.

Historical Perspective

  • Peritoneal carcinomatosis was first described by Swerdlow in 1959.[1]

Classification

According to the Gilly classification, peritoneal carcinomatosis may be classified according to nodule size and intraperitoneal involvement (localized or diffuse) into 4 categories:[2]

  • 0 - No macroscopic disease
  • 1 - Malignant granulations less than 5 mm in diameter localized in one part of the abdomen
  • 2 - Malignant granulations less than 5 mm in diameter diffuse to the whole abdomen
  • 3 - Localized or diffuse malignant granulations 5–20 mm in diameter
  • 4 - Localized or diffuse large malignant masses (more than 2 cm in diameter)

Pathophysiology

  • The pathogenesis of peritoneal carcinomatosis is characterized by the malignant seeding of a tumor in the peritoneal cavity.[3]
  • Peritoneal carcinogenesis arises from the celomic epithelium lining of the abdominal cavity (peritoneum) in response to an oncogenic stimulus.[3]
  • The mutation on BRCA1/BRCA2 has been associated with the development of peritoneal carcinomatosis.
  • On gross pathology, characteristic findings of peritoneal carcinomatosis, include:[4]
    • Multilocular thin-walled cysts containing serous fluid
    • Occasionally unilocular
    • May be up to 15 cm
    • Adherent to the surface
  • On microscopic histopathological analysis, characteristic findings of peritoneal carcinomatosis, include:[4]

Causes

Common causes of peritoneal carcinomatosis, include:[4]

Peritoneal carcinomatosis may also be caused by a mutation in the BCRA1 or BCRA2 genes.

Differentiating Peritoneal Carcinomatosis from Other Diseases

Peritoneal carcinomatosis must be differentiated from other diseases that cause abdominal pain, ascites, and weight loss, such as:[4]

Differentiating peritoneal carcinomatosis from other diseases
Disease Prominent clinical findings Lab tests Tratment
Primary peritonitis Spontaneous bacterial peritonitis
Tuberculous peritonitis
Continuous Ambulatory Peritoneal Dialysis (CAPD peritonitis)
Secondary peritonitis Acute bacterial secondary peritonitis
Biliary peritonitis
Tertiary peritonitis
Familial Mediterranean fever (periodic peritonitis, familial paroxysmal polyserositis)
  • Colchicine prevents but does not treat acute attacks.
Granulomatous peritonitis
  • Diagnosed by the demonstration of diagnostic Maltese cross pattern of starch particles.
Sclerosing encapsulating peritonitis
Intraperitoneal abscesses
  • Diagnosed best by CT scan of the abdomen.
  • Treatment consists of prompt and complete CT or US guided drainage of the abscess, control of the primary cause, and adjunctive use of effective antibiotics. Open drainage is reserved for abscesses for which percutaneous drainage is inappropriate or unsuccessful.
Peritoneal mesothelioma
peritoneal carcinomatosis

Epidemiology and Demographics

  • The prevalence of peritoneal carcinomatosis is approximately 0.03 per 100,000 individuals worldwide.[5]

Age

  • Peritoneal carcinomatosis is more commonly observed among patients aged 50 - 70 years.[6]
  • Peritoneal carcinomatosis is more commonly observed among adults.[7]

Gender

  • Females are more commonly affected with peritoneal carcinomatosis than males.[7]

Race

  • There is no racial predilection for peritoneal carcinomatosis.[7]

Risk Factors

The most important risk factor in the development of peritoneal carcinomatosis include:

Natural History, Complications and Prognosis

Diagnosis

Diagnostic Criteria

The diagnosis of peritoneal carcinomatosis is made when at least the following diagnostic criteria are met:[6]

  • Imaging findings compatible with peritoneal carcinomatosis (see below)
  • Elevated protein concentration (more than 4.0 g/dL)
  • Abnormal serum-ascites albumin gradient (less than 1.1 g/dL)
  • High cell count (lymphocyte predominance)

Symptoms

  • Peritoneal carcinomatosis is usually asymptomatic.
  • Symptoms of peritoneal carcinomatosis may include the following:[4]

Physical Examination

  • Patients with peritoneal carcinomatosis usually appear pale and lethargic.
  • Physical examination may be remarkable for:[4]

Inspection

  • Enlarged abdomen
  • Abdominal distension

Palpation

  • Bulging of the flanks or shifting dullness
  • Fluid thrill or fluid wave
  • Other physical examination findings may include:

Laboratory Findings

  • Laboratory findings consistent with the diagnosis of peritoneal carcinomatosis, include:[7]

Imaging Findings

  • Enhanced CT scan is the imaging modality of choice for peritoneal carcinomatosis.[6]
  • On CT, peritoneal carcinomatosis is characterized by the following findings:[4]
  • Smooth or nodular peritoneal thickening and enhancement.
  • Implants on the liver and the splenic surfaces are frequently seen and result in scalloping of the surface by the masses.
  • Sites of tumor implantation are the intersegmental fissure, superior recess of the lesser sac, subphrenic space, and Morison pouch.
  • Usually there is large ascites, which is often loculated.
  • The images below demonstrate a case of peritoneal carcinomatosis.

Other Diagnostic Studies

  • Peritoneal carcinomatosis may also be diagnosed using abdominal paracentesis.
  • Findings on paracentesis may include:

Treatment

Medical Therapy

Surgery

  • Cytoreductive surgery is the mainstay of therapy for peritoneal carcinomatosis.[9]
  • Laparotomy in conjunction with cytology testing is the most common approach to the treatment of peritoneal carcinomatosis.
  • Cytoreductive surgery is composed of three steps: Exploration of the abdominal cavity, debulking and chemoperfusion.

Prevention

  • There are no primary preventive measures available for peritoneal carcinomatosis.
  • Once diagnosed and successfully treated, patients with peritoneal carcinomatosis are followed-up every 1, 3 or 6 months.
  • Follow-up testing includes ultrasound, paracentesis, and abdominal examination.[6]

References

  1. Swerdlow M: Mesothelioma of the pelvic peritoneum resembling papillary cystadenocarcinoma of the ovary: Case report. Am J Obstet Gynecol 77:200, 1959.
  2. Kianmanesh R, Ruszniewski P, Rindi G, Kwekkeboom D, Pape UF, Kulke M, Sevilla Garcia I, Scoazec JY, Nilsson O, Fazio N, Lesurtel M, Chen YJ, Eriksson B, Cioppi F, O'Toole D (2010). "ENETS consensus guidelines for the management of peritoneal carcinomatosis from neuroendocrine tumors". Neuroendocrinology. 91 (4): 333–40. doi:10.1159/000286700. PMID 20424420.
  3. 3.0 3.1 3.2 Deraco M, Santoro N, Carraro O, Inglese MG, Rebuffoni G, Guadagni S, Somers DC, Vaglini M (1999). "Peritoneal carcinomatosis: feature of dissemination. A review". Tumori. 85 (1): 1–5. PMID 10228488.
  4. 4.0 4.1 4.2 4.3 4.4 4.5 4.6 Peritoneum. Libre patholgy. https://librepathology.org/wiki/Peritoneum Accessed on April 7, 2016
  5. Segelman J, Granath F, Holm T, Machado M, Mahteme H, Martling A (2012). "Incidence, prevalence and risk factors for peritoneal carcinomatosis from colorectal cancer". Br J Surg. 99 (5): 699–705. doi:10.1002/bjs.8679. PMID 22287157.
  6. 6.0 6.1 6.2 6.3 Villanueva A, Pérez C, Sabaté JM, Llauger J, Giménez A, Sanchis E, García T, Moreno A (1995). "[Peritoneal carcinomatosis. Review of CT findings in 107 cases]". Rev Esp Enferm Dig (in Spanish; Castilian). 87 (10): 707–14. PMID 8519536.
  7. 7.0 7.1 7.2 7.3 Kusamura S, Baratti D, Zaffaroni N, Villa R, Laterza B, Balestra MR, Deraco M (2010). "Pathophysiology and biology of peritoneal carcinomatosis". World J Gastrointest Oncol. 2 (1): 12–8. doi:10.4251/wjgo.v2.i1.12. PMC 2999153. PMID 21160812.
  8. Thomassen I, van Gestel YR, Lemmens VE, de Hingh IH (2013). "Incidence, prognosis, and treatment options for patients with synchronous peritoneal carcinomatosis and liver metastases from colorectal origin". Dis. Colon Rectum. 56 (12): 1373–80. doi:10.1097/DCR.0b013e3182a62d9d. PMID 24201391.
  9. 9.0 9.1 9.2 Glockzin G, Schlitt HJ, Piso P (2009). "Peritoneal carcinomatosis: patients selection, perioperative complications and quality of life related to cytoreductive surgery and hyperthermic intraperitoneal chemotherapy". World J Surg Oncol. 7: 5. doi:10.1186/1477-7819-7-5. PMC 2639355. PMID 19133112.