Peritoneal metastases in children with cancer

Department of Pediatrics , Stanford University, Stanford, California, United States
Cancer (Impact Factor: 4.89). 08/1998; 83(2):385-90. DOI: 10.1002/(SICI)1097-0142(19980715)83:2<385::AID-CNCR25>3.0.CO;2-O
Source: PubMed
ABSTRACT
This study attempted to evaluate the childhood malignancies associated with computed tomography (CT) detected peritoneal metastases as well as the diagnostic imaging characteristics of these metastases as shown on CT.
The authors reviewed all available pathology specimens and abdominopelvic CT scans of patients identified as having peritoneal metastases at three childhood cancer centers. Patient demographics, primary diagnosis, and CT characteristics of such metastases were evaluated.
Peritoneal metastases were identified by CT in 32 children with cancer either at diagnosis (n = 20) or up to 6.2 years from diagnosis (n = 12). On CT, peritoneal disease appeared as a mass in 26 cases, as studding in 11 cases, as peritoneal enhancement in 15 cases, and as diffuse caking in 4 cases (15 patients had > 1 category of peritoneal metastasis). Thirteen patients had concurrent metastases in other sites. Fourteen patients died of progressive disease at a median of 10 months from the time peritoneal metastases were identified on CT. At last follow-up, the remaining 18 patients were alive, with follow-up ranging from 1 month to 9.7 years. As expected, peritoneal metastases were identified in patients with germ cell tumors and colon carcinoma. However, they also were observed in patients with epithelioid carcinoma, leiomyosarcoma, pineoblastoma, neuroblastoma, melanoma, and peripheral neuroectodermal tumor.
Peritoneal metastases have variable appearance on CT, but most commonly appear mass-like. They are associated with a wider range of primary diagnoses than reported previously. The outcome varies with the type of the primary tumor and its responsiveness to existing therapies.

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Peritoneal Metastases in Children with Cancer
Sue C. Kaste,
D.O.
1,2
Neyssa Marina,
M.D.
3
Ray Fryrear,
B.S.
4
Gary L. Hedlund,
D.O.
5
Luann Jones,
M.D.
6
Debbie Poe,
C.C.R.A.
4
Jesse J. Jenkins III,
M.D.
7,8
1
Department of Diagnostic Imaging, St. Jude Chil-
dren’s Research Hospital, Memphis, Tennessee.
2
Department of Radiology, University of Tennes-
see-Memphis, Memphis, Tennessee.
3
Department of Pediatrics, Stanford University
Medical Center, Stanford, California.
4
Department of Hematology-Oncology, St. Jude
Children’s Research Hospital, Memphis, Tennes-
see.
5
Department of Pediatric Imaging, Children’s Hos-
pital, Birmingham, Alabama.
6
Department of Radiology, Stanford University
Medical Center, Stanford, California.
7
Department of Pathology, St. Jude Children’s
Research Hospital, Memphis, Tennessee.
8
Department of Pathology, University of Tennes-
see-Memphis, Memphis, Tennessee.
Supported in part by Grants P30 CA-21765 and
P01 CA-23099 from the National Cancer Institute
and by the American Lebanese Syrian Associated
Charities (ALSAC).
Address for reprints: Sue C. Kaste, D.O., Depart-
ment of Diagnostic Imaging, St. Jude Children’s
Research Hospital, 332 N. Lauderdale, Memphis,
TN 38105–2794. Received June 25, 1997; ac-
cepted January 19, 1998.
BACKGROUND. This study attempted to evaluate the childhood malignancies asso-
ciated with computed tomography (CT) detected peritoneal metastases as well as
the diagnostic imaging characteristics of these metastases as shown on CT.
METHODS. The authors reviewed all available pathology specimens and abdomi-
nopelvic CT scans of patients identified as having peritoneal metastases at three
childhood cancer centers. Patient demographics, primary diagnosis, and CT char-
acteristics of such metastases were evaluated.
RESULTS. Peritoneal metastases were identified by CT in 32 children with cancer
either at diagnosis (n 5 20) or up to 6.2 years from diagnosis (n 5 12). On CT,
peritoneal disease appeared as a mass in 26 cases, as studding in 11 cases, as
peritoneal enhancement in 15 cases, and as diffuse caking in 4 cases (15 patients
had . 1 category of peritoneal metastasis). Thirteen patients had concurrent
metastases in other sites. Fourteen patients died of progressive disease at a median
of 10 months from the time peritoneal metastases were identified on CT. At last
follow-up, the remaining 18 patients were alive, with follow-up ranging from 1
month to 9.7 years. As expected, peritoneal metastases were identified in patients
with germ cell tumors and colon carcinoma. However, they also were observed in
patients with epithelioid carcinoma, leiomyosarcoma, pineoblastoma, neuroblas-
toma, melanoma, and peripheral neuroectodermal tumor.
CONCLUSIONS. Peritoneal metastases have variable appearance on CT, but most
commonly appear mass-like. They are associated with a wider range of primary
diagnoses than reported previously. The outcome varies with the type of the
primary tumor and its responsiveness to existing therapies. Cancer 1998;83:
385–90. © 1998 American Cancer Society.
KEYWORDS: peritoneal, metastases, computed tomography (CT), childhood cancer.
T
he lungs represent the principal site of metastases for most child-
hood solid tumors, but dissemination to the liver, bone, and brain
account for significant morbidity and mortality.
1
Little is known re-
garding the frequency and impact of the presence of peritoneal me-
tastases in children with cancer. The few available reports of perito-
neal metastases in these patients have focused on the association of
pseudomyxoma peritonei with teratomas
2
and with mucinous tumors
of the appendix
3–7
or ovary.
8–11
Single instances of pseudomyxoma
peritonei associated with dermatomyositis
12
and metastatic colloid
carcinoma of the breast
13
also have been reported. There is some
confusion in the literature regarding the definitions of “pseudo-
myxoma peritonei” and “peritoneal implants.” In this study, we will
reserve the former term for a rare process in which omental and
peritoneal surfaces are caked with histologically benign gelatinous
mucinous implants,
3,5,8–10,12,14
whereas the latter term will refer to
metastatic involvement of the peritoneum by a primary cancer that
did not arise from the peritoneum itself. Likewise, this study was not
designed to determine the sensitivity and specificity of computed
385
© 1998 American Cancer Society
Page 1
tomography (CT) in identifying peritoneal metastases,
but rather to review our experience with CT-identified
peritoneal metastases in childhood cancer patients.
PATIENTS AND METHODS
A search of the institutional computer data base at St.
Jude Children’s Research Hospital (SJCRH) identified
45 patients coded as having peritoneal implants over a
32-year period. Of these patients, 22 had abdominal
CT scans available for review; the remaining 23 pa-
tients were treated prior to the advent of CT. Patients
with abdominal mesothelioma and pseudomyxoma
peritonei were excluded from the study. Only patients
for whom CT scans demonstrated evidence of perito-
neal metastases will be discussed. A pediatric pathol-
ogist (J.J.J.) reviewed all available pathology specimens
to confirm the primary diagnosis and the presence of
peritoneal disease at SJCRH. Also included in this
study were three cases of CT-identified peritoneal im-
plants from Stanford University Medical Center and
seven cases from the Children’s Hospital of Alabama.
Imaging was reviewed by pediatric radiologists at
these institutions (S.C.K., L.J., and G.H., respectively).
All patients were treated on disease specific protocols
approved by the appropriate institutional review
board. We recorded patient demographics, primary
diagnosis, and clinical course and outcome for all
patients.
Patients were imaged using GE HiSpeed Advan-
tage or GE 9800 (General Electric Systems, Milwaukee,
WI), Siemens Somatom Plus, Siemens Somatom Plus
4, Siemens Imatron Evolution EBT, or Siemens DRH
CT scanners (Siemens Medical Systems, Iselin, NJ)
with intravenous and oral contrast administration. All
CT scans were rereviewed by a pediatric radiologist
(S.C.K., L.J., and G.H.) for the presence or absence of
peritoneal implants, their characteristics, and the time
from initial diagnosis to detection of metastases. In
terms of imaging features, cases with peritoneal dis-
ease were characterized as mass-like appearance (soft
tissue masses, distinct from the primary lesion), peri-
toneal enhancement (exaggerated enhancement
and/or smooth peritoneal thickening), omental caking
(matted disease involving the peritoneum; frequently
concurrently involving omentum and bowel), or peri-
toneal studding (irregular or nodular appearance of
the peritoneal surfaces).
RESULTS
The study population was comprised of 32 patients
with peritoneal metastases initially identified on CT.
The median age at diagnosis was 12.7 years (range, 10
months-20.5 years). Fourteen patients were boys; 18
were white, 10 were African-American, and 4 were
Hispanic. Peritoneal metastases were identified at the
time of initial diagnosis in 20 patients, 8 of whom had
concurrent nonperitoneal metastases. Peritoneal me-
tastases were identified between 2 months to 6.2 years
(median, 1.1 years) from diagnosis (Table 1) in the
remaining 12 patients, 5 of whom had other concur-
rent sites of metastases. Primary tumor types includ-
ed: extracranial teratoma or germ cell tumor (seven
patients), colon carcinoma (five patients), rhabdo-
myosarcoma (four patients), Wilms’ tumor (three pa-
tients), desmoplastic small round cell tumor (one pa-
tient), small blue round cell tumor (not otherwise
specified) (two patients), malignant melanoma (two
patients), non-Hodgkin’s lymphoma (two patients),
pineoblastoma (one patient; this patient also required
placement of a ventriculoperitoneal shunt), leiomyo-
sarcoma (one patient), neuroblastoma (one patient),
juvenile granulosa cell tumor (one patient), primitive
neuroectodermal tumor (one patient), and epithelioid
carcinoma (one patient). In total, 13 patients had con-
current metastatic disease involving organ systems
other than the peritoneal cavity.
Figures 1 to 4 illustrate the four diagnostic imag-
ing features observed on review of abdominopelvic CT
imaging. The peritoneal metastases were character-
ized as mass lesions in 26 cases, peritoneal enhance-
ment in 15 cases, peritoneal studding by small im-
plants in 11 cases, and diffuse caking by metastatic
tumor in 4 tumors; 15 patients had . 1 type of me-
tastasis identified.
Review of pathologic material from all 22 cases
treated at SJCRH identified peritoneal metastases at
diagnosis in 10 patients, 9 of which also were visual-
ized by CT at diagnosis. CT suggested peritoneal me-
tastases in one additional patient that were not con-
firmed on pathologic study.
At last follow-up, 14 of the 32 patients identified in
this study had died of disease. The median survival
after identification of the metastases for this group
was 10 months (range, 1 month-2.7 years); with 3
patients dying within 2 months. The remaining 18
patients were alive at a median of 1.9 years (range, 1
month-9.7 years) after detection of peritoneal im-
plants, while receiving disease-appropriate treatment.
DISCUSSION
Our review of 32 pediatric cancer patients with peri-
toneal metastases identified by CT revealed a variety
of primary tumors. It is not surprising that a large
proportion of these patients had either germ cell tu-
mors (25%) or colon adenocarcinoma (22%). These
tumors frequently have mucinous histopathology and
are known to metastasize to the peritoneum and
omentum.
15,16
The wide range of primary diagnoses in
386 CANCER July 15, 1998 / Volume 83 / Number 2
Page 2
our series is somewhat surprising. It also is possible
that patients with other types of tumors may have
developed peritoneal metastases; because of the
methods by which cases were identified, a selection
bias was present that could account for the lack of
identification of these cases and underrepresentation
of other tumor types. The pathogenesis of peritoneal
metastasis is variable and may result from direct ex-
tension of cancer cells from the primary site of disease
with direct seeding of the peritoneal serosal surfac-
es,
17–20
by hematogenous dissemination,
1,19–23
or by
lymphatic spread of disease.
24
Alternatively, perito-
neal metastases may represent a multifocal neoplastic
process,
7
and occasionally have been noted in patients
with ventriculoperitoneal shunts.
19,20,25–27
In one se-
ries describing 30 patients whose treatment included
TABLE 1
Characteristics, CT Features, and Outcome in 32 Patients with Peritoneal Metastases
Patient
no.
Age
(yrs) Gender Race Diagnosis
Time to
detection
(yrs) CT features Concurrent metastases
Status/survival
(yrs)
1 15.6 F B Colon carcinoma 0.0 Studding, peritoneal enhancement DOD/0.8
2 17.7 M W Colon carcinoma 0.2 Mass DOD/0.3
3 19.8 F W Colon carcinoma 0.0 Mass AWD/1.4
4 15.7 F B Colon carcinoma 0.8 Mass NED/9.7
5 15.9 F H Colon carcinoma
a
0.0 Mass DOD/1.1
6 2.4 M W Rhabdomyosarcoma
a
2.1 Mass PD/0.1
7 14.3 F W Rhabdomyosarcoma 0.0 Mass, peritoneal enhancement DOD/1.4
8 4.7 M H Rhabdomyosarcoma 1.8 Mass, peritoneal enhancement, studding,
caking
DOD/0.4
9 13.8 M B Rhabdomyosarcoma
a
0.0 Mass, studding Lung, mediastinal lymph
nodes
PD/0.9
10 9.2 F W Teratoma 0.0 Mass NED/2.0
11 11.2 F W Teratoma 0.0 Mass NED/9.0
12 11.7 F B Teratoma
a
0.2 Mass, studding PD/1.8
13 15.1 F W Germ cell tumor 1.1 Mass, peritoneal enhancement DOD/1.4
14 8.4 F B Ovarian germ cell tumor 0.0 Mass, studding, peritoneal enhancement NED/9.4
15 12.0 F W Ovarian germ cell tumor 0.2 Mass, peritoneal enhancement DOD/1.0
16 9.2 M B Wilms’ tumor 0.2 Mass, peritoneal enhancement, studding Liver, lung DOD/0.7
17 2.6 F B Wilms’ tumor
a
3.3 Mass DOD/1.3
18 3.0 F B Wilms’ tumor 0.4 Mass DOD/0.9
b
19 8.7 F W Small blue round cell
tumor
a
0.0 Mass, caking Bone DOD/0.9
20 13.0 F H Small blue round cell
tumor
a
0.3 Mass, peritoneal enhancement, studding Bone DOD/1.0
21 5.9 M W Non-Hodgkin’s
lymphoma
a
0.0 Peritoneal enhancement Liver CR/0.2
22 17.2 M W Non-Hodgkin’s
lymphoma
0.0 Caking Internal mammary lymph
nodes
NED/0.3
23 13.8 M W Melanoma 0.5 Peritoneal enhancement, studding, caking Liver DOD/0.2
24 0.8 M W Melanoma 3.6 Mass Cervical lymph nodes DOD/0.1
25 18.9 F W Endodermal tumor 0.0 Peritoneal enhancement NED/6.8
26 20.5 M W Desmoplastic small
round cell
a
0.0 Mass PD/3.3
27 12.7 F W Juvenile granulosa cell
tumor
0.0 Mass, peritoneal enhancement PD/2.0
28 13.6 F W PNET 0.0 Mass, studding, peritoneal enhancement Internal mammary lymph
nodes
DOD/2.7
29 2.2 M B Pineoblastoma 1.1 Mass, peritoneal enhancement Leptomeninges DOD/0.1
30 15.5 M B Leiomyosarcoma 0.0 Mass, studding, peritoneal enhancement DOD/1.1
31 3.4 M H Neuroblastoma 6.2 Mass Bone, orbit, temporal bone PD/3.8
32 14.3 M W Epithelioid carcinoma
a
0.0 Studding Bone, lung, lymph nodes PD/0.2
CT: computed tomography; F: female; B: black; DOD: died of disease; M: male; W: white; AWD: alive with disease; H: Hispanic; NED: no evidence of disease; PD: progressive disease; CR: complete response; PNET:
peripherial neuroectodermal tumor.
a
Patient not treated at St. Jude Children’s Research Hospital.
b
This patient died of secondary acute myelocytic leukemia. Autopsy revealed persistent active intraabdominal disease.
Peritoneal Metastases in Childhood Cancer/Kaste et al. 387
Page 3
ventriculoperitoneal shunting, 1 patient developed
peritoneal metastases of an undifferentiated germ cell
tumor at the time of intracranial recurrence.
19
One
child in our series developed peritoneal metastases
associated with the presence of ventriculoperitoneal
shunting. Although systemic metastases are not a pre-
requisite for the presence of peritoneal metastases,
7,18
nearly 50% of the patients in our series had metastases
involving other abdominal organs, as well as lungs,
bone, or distant lymph node chains at the time peri-
toneal implants were identified.
Noninvasive identification of peritoneal metasta-
ses has improved considerably with the advent of
CT.
11,14,28
However, the detection of peritoneal im-
plants is limited by the lesion size,
11,29
paucity of in-
traabdominal fat, contiguity with the primary tumor,
28
presence or absence of ascites, implant location,
30
and
adequacy of bowel opacification. Current CT scanners
are able to detect approximately 50% of surgically
proven peritoneal implants as small as 5 mm.
11,14
More recent series suggest that magnetic resonance
imaging (MRI) of the abdomen and pelvis may further
improve detection because of inherent tissue contrast
and the multiplanar capability of MRI.
30,31
The CT characteristics of peritoneal metastases in
FIGURE 1. A 17-year-old boy (Patient 22) was diagnosed with primary
abdominal non-Hodgkin’s lymphoma. At the time of initial presentation, an axial
computed tomography image obtained through the lower abdomen showed
diffuse caking of the peritoneum by tumor that encased all visualized loops of
bowel. In a case such as this, primary and metastatic disease may become
confluent, and/or indistinguishable from each other. At last follow-up the
patient was alive and receiving therapy, with no evidence of disease.
FIGURE 2. A 14-year-old girl (Patient 28) was diagnosed with primitive
neuroectodermal tumor of the pelvis. Diffuse peritoneal enhancement in the
presence of abundant ascites was demonstrated on this contrast-enhanced,
axial abdominal computed tomography image. The patient died 2.5 years later
of progressive metastatic disease.
FIGURE 3. (a and b) Contrast-enhanced, axial abdominal computed tomog-
raphy images showed extensive mixed attenuation metastases studding the
peritoneal surfaces in this girl age 15.5 years (Patient 1) with colon carcinoma.
Peritoneal implants studded the gallbladder wall (arrows) and extended along
the peritoneal reflections (arrowheads). There was subtle diffuse enhancement
of the peritoneum (open arrows), contrasted by abundant ascites.
388 CANCER July 15, 1998 / Volume 83 / Number 2
Page 4
our series (i.e., mass-like, peritoneal enhancement,
peritoneal studding, and caking) are similar to those
reported by Whitley et al.
15
We identified solitary or
multiple peritoneal masses, peritoneal enhancement,
and/or studding in each of the tumor types in our
series. However, diffuse caking was observed only in
patients with rhabdomyosarcoma, non-Hodgkin’s
lymphoma, and germ cell tumors.
The appreciation of peritoneal metastases may
vary by reviewer experience and sensitivity. In our
experience, diffuse peritoneal thickening and en-
hancement are more difficult to identify than focal
masses. Diffuse peritoneal carcinomatosis can mimic
extensive ascites, as observed in one of our cases of
primary paratesticular rhabdomyosarcoma. Central-
ization of bowel loops commonly observed in the
presence of abundant ascites may be absent in cases
of extensive peritoneal metastases, in which bowel
loops may be separated by tumor and fixed in posi-
tion.
The detection of metastatic disease to the perito-
neum occurred as an immediate preterminal event in
3 patients, with death from progressive disease ensu-
ing within 2 months. An additional 11 patients sur-
vived up to 2.7 years prior to dying of progressive
disease, and 18 remained alive at up to 9.7 years.
Peritoneal metastases may be associated with a
wide variety of nonmucinous as well as mucinous
childhood tumors. Our study suggests that the pres-
ence of peritoneal metastases is not limited to tumors
such as colon carcinoma or germ cell tumors but also
can occur with sarcomas and other small round cell
tumors either at diagnosis or after tumor progression.
Their detection is dependent on a high level of suspi-
cion as well as improved sensitivity of newer imaging
modalities. In addition, it appears that the presence of
peritoneal metastases does not necessarily predict a
worse outcome, but is dependent on the specific di-
agnosis and the response to treatment.
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