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Peritoneal Metastasis

2 Malig Neop Peritoneum

Peritoneal metastasis is a known complication of advanced gastrointestinal, primary peritoneal (mesotheliomas), and genitourinary malignancies and brings a very poor prognosis. The clinical presentation is initially asymptomatic, but at some point, complaints of abdominal pain, weight loss, and ascites appear. The diagnosis is made through the use of imaging studies, such as computed tomography (CT), magnetic resonance imaging (MRI), and positron-emission tomography (PET).


Presentation

Metastatic spread of malignant tumors into the peritoneum, a two-layered (parietal and visceral) mesothelial lining, is almost universally fatal within a short period of time, as only palliative therapeutic measures may be implemented at this stage of progression [1] [2] [3] [4] [5]. Neoplasms of the gastrointestinal system (particularly colorectal cancer) and the genitourinary tract, as well as hepatic, pancreatic, and primary peritoneal tumors (mesothelioma), are known for their propensity to metastasize into this anatomical landmark, and they are able to do so in several ways [1] [2] [4] [6]. Proximal masses (eg. gastrointestinal or ovarian cancers) are able to directly penetrate into the peritoneum, whereas spread via the lymphatic or hematogenous routes (typical for more distant primary malignancies, such as melanoma, lung cancer, or breast cancer), as well as intraperitoneal dissemination of the tumor through ascitic fluid (a potential complication during surgical procedures), are other possible routes [1] [2] [6]. The clinical presentation of peritoneal metastasis is quite variable, and often depends on the location and the severity of tumor invasion, but in most cases, the initial course is asymptomatic [2]. The majority of patients, however, develop symptoms of abdominal pain, distension, and discomfort (developing as a result of bowel obstruction), followed by weight loss, nausea, vomiting, and severe fatigue with cachexia [1] [2] [4].

Weight Loss
  • The clinical presentation is initially asymptomatic, but at some point, complaints of abdominal pain, weight loss, and ascites appear.[symptoma.com]
  • We report an unusual presentation of chronic appendicitis with a synchronous peritoneal nodule on CT in a 76-year-old woman who presented with poor appetite, weight loss and a mass in the right iliac fossa.[ncbi.nlm.nih.gov]
  • Symptoms and Diagnosis The symptoms of local spread of bowel cancer can be vague, but are likely to include unexplained pain, tenderness over the area, or unusual discharges, changed appetite or unexpected weight loss.[bowelcanceraustralia.org]
  • Peritoneal mesothelioma symptoms, such as abdominal swelling, weight loss and hernias, also arise in other abdominal cancers and many less serious conditions. This overlap of symptoms increases the likelihood of a misdiagnosis.[asbestos.com]
  • He also complained of a 50-lb weight loss and gross hematuria over one-year period. For further evaluation, abdominal CT was done, revealing ascites and omental thickening (Figure 1).[ijcasereportsandimages.com]
Abdominal Pain
  • The clinical presentation is initially asymptomatic, but at some point, complaints of abdominal pain, weight loss, and ascites appear.[symptoma.com]
  • During CCRT, she suffered from acute lower abdominal pain, high fever, and leukocytosis.[ncbi.nlm.nih.gov]
  • Two months after initiation of chemotherapy, he complained of vomiting and abdominal pain. A computed tomography scan revealed marked thickening of the sigmoid colon wall adjacent to the catheter of the i.p. access port system.[ncbi.nlm.nih.gov]
  • During these therapies, the patient developed a fever and mild abdominal pain, which was associated with an increased C-reactive protein level.[ncbi.nlm.nih.gov]
  • The most frequent grade 3/4 adverse events were neutropenia (38.6%) and abdominal pain (30.8%). The incidence of abdominal pain cumulatively increased in the later treatment cycles.[ncbi.nlm.nih.gov]
Abdominal Mass
  • The abdominal mass was 26 x 17 x 12 cm in size, as determined by magnetic resonance imaging, and was diagnosed as a peritoneal relapse of GIST. Treatment with 400 mg of imatinib daily was started.[ncbi.nlm.nih.gov]
  • Abstract Solid and papillary epithelial neoplasm of the pancreas is a low-grade malignant tumor, generally occurring as a slowly growing upper abdominal mass in a young female. With complete excision, the prognosis is good.[ncbi.nlm.nih.gov]
  • A 25-year-old Indian man presented with a large abdominal mass. A computed tomography scan revealed a large 18 cm-sized mass in his transverse colon, suggestive of gastrointestinal stromal tumor. A wide local excision was performed.[ncbi.nlm.nih.gov]
Constipation
  • Gastrointestinal symptoms (nausea/vomiting, constipation, diarrhoea, anorexia) remained stable under PIPAC therapy.[ncbi.nlm.nih.gov]
  • The beginning symptoms of peritoneal mesothelioma include abdominal distension, abdominal pain, swelling or tenderness around the abdomen and constipation or diarrhea.[asbestos.com]
Pelvic Mass
  • We present a case of a 36-year-old woman with cough, hemoptysis, dyspnea with detection of lung mass, and incidental detection of pelvic mass. Fine needle aspiration cytology failed to reveal the true nature of both the lesions.[ncbi.nlm.nih.gov]

Workup

The clinical manifestation of peritoneal metastasis is nonspecific, but the observation of a newly formed ascites must raise suspicion toward a malignant etiology [2]. For this reason, the physician must obtain a detailed patient history that will assess the duration of symptoms, their onset, as well as progression, whereas anamnestic data of malignant diseases is crucial for making a presumptive diagnosis. In fact, up to 50% of gastric cancers and 10-35% of colorectal cancers recur as peritoneal metastasis [3]. After a thorough physical examination, imaging studies need to be employed. Abdominal ultrasonography, a common first-line procedure, provides little benefit when it comes to visualizing the metastatic deposits, but its use as a guide to obtain a viable sample of the ascitic fluid or of superficial tumors for histopathological testing is invaluable [6]. Instead, more advanced methods - computed tomography and magnetic resonance imaging are the cornerstones for identifying peritoneal metastasis and tumor spread [2] [3] [6] [7]. Typical findings range from multifocal nodules to aggressive infiltrating masses, whereas stellate lesions and calcifications might also be encountered [2] [7]. MRI is particularly effective if used with gadolinium as a contrast, and images should be obtained 5-10 minutes after the agent is administered [2]. The diagnosis can be further solidified through the use of fluorodeoxyglucose (FDG)-PET [2].

Treatment

  • RESULTS: Patients whose treatment was changed based on symptoms/TMs had significantly longer OS than patients with computed tomographic-based treatment change (p 0.04).[ncbi.nlm.nih.gov]
  • Treatment with 400 mg of imatinib daily was started. After 1 week of treatment with imatinib, reduction of the abdominal tumor began to be recognized on palpation.[ncbi.nlm.nih.gov]
  • CRS and HIPEC for PM were compared in others trials with different intraperitoneal treatments without hyperthermia or with no intraperitoneal treatment or with intravenous chemotherapy. Inclusions were closed for the French study - PRODIGE 7.[ncbi.nlm.nih.gov]
  • Additionally, ouabain treatment led to inflammatory cells infiltration into the submucosa and a decreased volume of ICCs.[ncbi.nlm.nih.gov]
  • With advances in treatments, unusual sites of metastasis may become more prevalent.[ncbi.nlm.nih.gov]

Prognosis

  • BACKGROUND/AIMS: Peritoneal metastasis (PM) is a well-known predictor of poor prognosis. This study aims at identifying factors affecting recurrence and prognosis after R0 resection for colorectal cancer (CRC) with synchronous PM.[ncbi.nlm.nih.gov]
  • The aim of this study was to investigate the factors affecting recurrence and prognosis after R0 resection for colorectal cancer with synchronous peritoneal metastases.[ncbi.nlm.nih.gov]
  • Abstract Being the major reason of recurrence and death after surgery, peritoneal metastasis of gastric cancer dooms the prognosis of advanced gastric cancer patients.[ncbi.nlm.nih.gov]
  • BACKGROUND: Tumors that show a signet ring or adenocarcinoid histomorphology have been associated with a poor prognosis.[ncbi.nlm.nih.gov]
  • Right colon cancer, early peritoneal metastasis, a high PCI, and concurrent metastases negatively affected prognosis in patients with metachronous peritoneal metastasis.[ncbi.nlm.nih.gov]

Etiology

  • The clinical manifestation of peritoneal metastasis is nonspecific, but the observation of a newly formed ascites must raise suspicion toward a malignant etiology.[symptoma.com]
  • Sari R, Yildirim B, Sevinc A, et al: The importance of serum and ascites fluid alpha-fetoprotein, carcinoembryonic antigen, CA 19-9, and CA 15-3 levels in differential diagnosis of ascites etiology.[mayomedicallaboratories.com]

Epidemiology

  • The epidemiology of patients with peritoneal metastases mirrors that of affected patients.[radiopaedia.org]
  • Epidemiology and risk factors of urothelial (transitional cell) carcinoma of the bladder. UptoDate. 2016. Steinberg GD. Bladder Cancer. Medscape. [Available at: ] Lotan, Yair L, Choueiri TK.[ijcasereportsandimages.com]
  • However, a recent investigation of the Surveillance Epidemiology and End Result (SEER) database did not support the merging of moderately and poorly differentiated grades into a single high-grade category as moderately differentiated tumors had a survival[wjgnet.com]
  • Asbestos: Risk Assessment, Epidemiology, and Health Effects, Second Edition. Taylor & Francis: Boca Raton, 2012. Bridda, A. et al. (2007). Peritoneal mesothelioma: A review. Med Gen Med., 9(2), 32. Retrieved from: Galateau-Salle, F.[asbestos.com]
  • Walter T, Scoazec J-Y, Lepage C: Epidemiology of digestive neuroendocrine tumors with focus on French data. Hépato-Gastro 2013;20:160-166.[karger.com]
Sex distribution
Age distribution

Pathophysiology

  • Useful For Suggests clinical disorders or settings where the test may be helpful An adjunct to cytology to differentiate between malignancy-related ascites and benign causes of ascites formation Clinical Information Discusses physiology, pathophysiology[mayomedicallaboratories.com]

Prevention

  • RESULTS: Four trials (Dutch, French, Italian and Spanish) focussed on a preventive strategy to decrease the rate of CRC-PM. Inclusions were closed for the French study - ProphyloCHIP.[ncbi.nlm.nih.gov]
  • The present report suggests the importance of paying close attention to procedures during laparoscopic colorectal resection to prevent peritoneal seeding. J. Med. Invest. 64: 288-290, August, 2017.[ncbi.nlm.nih.gov]
  • CONCLUSIONS: EPIC is a safe and efficacious option for intraperitoneal chemotherapy to prevent peritoneal recurrence and prolong survival after complete resection of peritoneal metastasis from colorectal cancer.[ncbi.nlm.nih.gov]
  • Preventing and controlling the development of peritoneal metastasis could play a role in helping to prolong the survival of gastric cancer patients.[ncbi.nlm.nih.gov]
  • The present report suggests the importance of paying close attention to procedures during laparoscopic colorectal resection to prevent peritoneal seeding. J. Med. Invest. 64: 288-290, August, 2017[jstage.jst.go.jp]

References

Article

  1. Bellavance EC, Alexander HR Jr. Palliative interventions in patients with peritoneal metastases and malignant bowel obstruction. J Clin Oncol. 2012;30(35):4290-4201.
  2. Levy AD, Shaw JC, Sobin LH. Secondary tumors and tumorlike lesions of the peritoneal cavity: imaging features with pathologic correlation. Radiographics. 2009;29(2):347-373.
  3. Coccolini F, Gheza F, Lotti M, et al. Peritoneal carcinomatosis. World J Gastroenterol. 2013;19(41):6979-6994.
  4. Klaver YL, Lemmens VE, Nienhuijs SW, Luyer MD, de Hingh IH. Peritoneal carcinomatosis of colorectal origin: Incidence, prognosis and treatment options. World J Gastroenterol. 2012;18(39):5489-5494.
  5. Raptopoulos V, Gourtsoyiannis N. Peritoneal carcinomatosis. Eur Radiol. 2001;11(11):2195-206.
  6. Healy JC. Detection of peritoneal metastases. Cancer Imaging. 2001;1(2):4-12.
  7. Agarwal A, Yeh BM, Breiman RS, Qayyum A, Coakley FV. Peritoneal calcification: causes and distinguishing features on CT. AJR Am J Roentgenol. 2004;182(2):441-445.

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Last updated: 2019-07-11 21:01