Title | Introduction | Histopathology | Computed Tomography | Clinical Assessment Criteria | Pharmacokinetics of IP Chemotherapy
Appendix Cancer Morphology | Cytoreductive Surgery | Perioperative Intraperitoneal Chemotherapy | Results of Treatment


Computed Tomography


   

Complete Resection
No.=25

Incomplete Resection
No.=20

 

Site

Tumor
Volume*

No.

Percent

No.

Percent

p Value

Proximal jejunum, left upper quadrant          

0.003

 

0

13

52

3

15

 
 

1

6

24

1

5

 
 

2

2

8

5

5

 
 

3

4

16

11

55

 
             
Distal jejunum, left lower quadrant          

0.002

 

0

8

32

2

10

 
 

1

3

12

0

0

 
 

2

10

40

4

20

 
 

3

4

16

14

70

 
             
Proximal ileum, right upper quadrant          

0.003

 

0

14

56

1

5

 
 

1

3

12

3

15

 
 

2

5

20

9

45

 
 

3

3

12

7

35

 
             
Distal ileum, right lower quadrant          

NS

 

0

5

20

1

5

 
 

1

7

28

1

5

 
 

2

6

24

4

20

 
 

3

7

28

14

70

 
             
* 0, no tumor; 1, tumor diameter <0.5 cm; 2, tumor diameter 0.5 to 5.0 cm; and 3, tumor diameter >5.0 cm or a confluence of disease.  
 
No., Number of patients, and NS, not significant.  
             

Table 6

Tumor volume in different portions of the small bowel as a predictor of complete versus incomplete cytoreduction of mucinous tumor. From Jacquet P, Jelinek JS, Chang D, Koslowe P, Sugarbaker PH: Abdominal computed tomographic scan in the selection of patients with mucinous peritoneal carcinomatosis for cytoreductive surgery. Journal of the American College of Surgeons 181:530-538, 1995.



         

Complete Resection
No.=25

Incomplete Resection
No.=20

 
Site        

No.

Percent

No.

Percent

p Value

Obstruction of bowel segment by tumor        

<0.001

  Present      

2

8

15

75

 
  Absent      

23

92

5

25

 
                   
Mesentery drawn together by tumor           <0.001
  Present      

9

36

19

95

 

 
  Absent      

16

64

1

5

 
                   
Peritoneal calcifications            

NS

  Present      

3

12

5

25

 
  Absent      

22

88

15

75

 
                   
Ureteral obstruction by tumor          

NS

  Present      

1

4

6

30

 
  Absent      

24

96

14

70

 
                   
Involvement of retroperitoneal nodes by tumor        

NS

  Present      

3

12

4

20

 
  Absent      

22

88

16

80

 
                   
No., Number of patients; and NS, not significant.          

Table 7

Computed tomographic findings of patients who underwent complete versus incomplete cytoreduction. From Jacquet P, Jelinek JS, Chang D, Koslowe P, Sugarbaker PH: Abdominal computed tomographic scan in the selection of patients with mucinous peritoneal carcinomatosis for cytoreductive surgery. Journal of the American College of Surgeons 181:530-538, 1995.



Figure 14

Predictive value of computed tomographic findings by a tree-structured diagram.
CR = complete resection; IR = incomplete resection; and RLQ = right lower quadrant.

From Jacquet P, Jelinek JS, Chang D, Koslowe P, Sugarbaker PH: Abdominal computed tomographic scan in the selection of patients with mucinous peritoneal carcinomatosis for cytoreductive surgery. Journal of the American College of Surgeons 181:530-538, 1995.



Figure 15A

CT image through the upper abdomen in a patient with pseudomyxoma peritonei. The liver is markedly distorted. There are globular tumor masses that have expanded to fill the space between the right and left hemidiaphragms. The demarcation between mucinous tumor and liver is distinct, suggesting an absence of invasion.



Figure 15B

CT image through the mid-abdomen in a patient with pseudomyxoma peritonei. The small bowel is compartmentalized by the large volume of mucinous ascites. The patient had a prior greater omentectomy, so that the "omental cake" was not present. Both small and large bowel show continued function. There are no air-fluid levels, and there is no dilation of the small bowel suggesting an absence of obstruction.



Figure 15C

CT image through the upper pelvis in a patient with pseudomyxoma peritonei. Both large and small bowels are compartmentalized by the mucinous tumor. Although there is some air within the small bowel, the quantity does not suggest small bowel obstruction. Despite the great volume of mucinous tumor, radiologically there appears to be preservation of bowel function.



Figure 15D

CT image through the lower pelvis in a patient with pseudomyxoma peritonei. The cul-de-sac is obliterated by mucinous tumor. The globular nature of mucin accumulations is evident. The patient shown in CT scans 15A through 15D underwent a complete cytoreduction with perioperative intraperitoneal chemotherapy. The patient remains disease-free at 72 months.



Figure 16A

CT image through the upper abdomen in a patient with intermediate grade mucinous adenocarcinoma of the appendix. The liver is markedly distorted, but a globular distortion is not evident. The interface of mucinous tumor and liver is more spiculated and less defined, suggesting an invasive component to the disease. The stomach is encased by tumor and the wall of the stomach is thickened circumferentially. A nodule of tumor is invading the upper portion of the spleen.



Figure 16B

CT image through the upper abdomen midway between xyphoid and umbilicus in a patient with intermediate grade mucinous adenocarcinoma of the appendix. Mucinous tumor has infiltrated the greater omentum and displaced the transverse colon inferiorly. There are some calcifications within the tumor.



Figure 16C

CT image at the level of the umbilicus in a patient with intermediate grade mucinous adenocarcinoma of the appendix. Tumor nodules are intimately associated with small bowel and small bowel mesentery throughout the abdomen. This intimate association of small bowel with mucinous tumor suggests that a complete cytoreduction is not possible.



Figure 16D

CT image through the pelvis in a patient with intermediate grade mucinous adenocarcinoma of the appendix. The cul-de-sac is obliterated by tumor. The patient in Figures 16A through 16D had a debulking procedure. This consisted of a total proctocolectomy, greater omentectomy and splenectomy. Tumor was left behind beneath the right and left hemidiaphragms and above the stomach in the lesser omentum. The patient did receive heated intraoperative intraperitoneal mitomycin C and early postoperative intraperitoneal 5-fluorouracil. Because of the CT findings, it was possible to inform the patient preoperatively that this was a palliative treatment that may prolong a high quality survival, but that long-term disease control should not be expected.



Figure 17

CT image through the upper abdomen in a patient with pseudomyxoma peritonei that has undergone multiple prior cytoreductive procedures without intraperitoneal chemotherapy. The tumor by way of fibrin entrapment is now intimately associated with multiple loops of small bowel. It is impacted around the liver. The small bowel shows air fluid levels compatible with segmental obstruction. The pelvis of the left kidney is dilated, suggesting compression by tumor along the course of the left ureter. This patient was not operated on selectively. Only as symptoms demand surgical palliation, will operative interventions be recommended.




Title | Introduction | Histopathology | Computed Tomography | Clinical Assessment Criteria | Pharmacokinetics of IP Chemotherapy
Appendix Cancer Morphology | Cytoreductive Surgery | Perioperative Intraperitoneal Chemotherapy | Results of Treatment