Gastrointest Radiol 17:16-18 (1992)
Gastrointestinal
Radiology 9 Springer-Verlag New York Inc. 1992
Pseudomyxoma Peritonei with Progressive Calcifications: CT Findings Yujiro Matsuoka, Kuni Ohtomo, Yuji Itai, Junichi Nishikawa, Koki Yoshikawa, and Yasuhito Sasaki Department of Radiology, University of Tokyo, Faculty of Medicine, Tokyo, Japan
Abstract. Development of abdominal calcifications due to pseudomyxoma peritonei is rare. The authors present three cases whereby computed tomographic (CT) studies during or after chemotherapy for pseudomyxoma peritonei demonstrated development and progression of punctate calcifications in the abdomen. The clinical and CT findings of these cases are presented together with a brief review of the pertinent literature. Key words: Abdomen, calcifications--Pseudomyxoma peritonei, CT diagnosis.
Pseudomyxoma peritoneal is characterized by mucinous ascites and implants throughout the abdominal cavity. The primary site is commonly the appendix or ovary. Calcification of pseudomyxoma peritonei is well known, but actually rare [1-14]. We report computed tomography (CT) of three cases showing development of progressive calcifications during or after chemotherapy.
Case Reports Case 1 A 40-year-old man Suffered from abdominal distension due to ascites. The cytology of the aspirated fluid was malignant and mucinous, suggesting pseudomyxoma peritonei. Initial CT demonstrated lobular hepatic indentations (Fig. IA). There was no .fiistory of surgery, and the cause of mucinous ascites was unknown. He was treated with intraperitoneal mitomycin C and intravenous fluorouracil (5-FU). The second CT 4 months later
Address offprint requests to: Yujiro Matsuoka, M.D., Department of Radiology, University of Tokyo, 7-3-1, Hongo, Bunkyoku, Tokyo 113, Japan
showed many punctate calcifications in the peritoneal cavity (Fig. IB). The calcifications became more prominent on the third CT 9 months after the initial diagnosis.
Case 2 A 61-year-old woman was diagnosed as having pseudomyxoma peritonei 5 years ago, following previous surgery for mucinous cystadenoma of the ovary. She had been treated with surgical resection of the recurrent tumor and chemotherapy for pseudomyxoma peritonei. The chemotherapy was both intraperitoneal and oral. CT showed many punctate calcifications in the peritoneal cavity 3 years after the first treatment (Fig. 2A). These calcifications increased within 1 year (Fig. 2B) and became much larger years later.
Case 3 A 73-year-old woman had surgery for mucinous cystadenocarcinoma of the ovary with pseudomyxoma peritonei. First CT showed peritoneal fluid collections without calcification. Seven months after treatment with intravenous cyclophosphamide (Endoxan), mitomycin C, and 5-FU, however, multifocal areas of small calcifications appeared in the peritoneum (Fig. 3A and B).
Discussion Pseudomyxoma peritoneal is essentially mucinous ascites; a rare complication of mucocele of the appendix and mucinous cystadenoma or cystadenocarcinoma of the ovary. Other primary sites are the colon, stomach, uterus, and pancreas, but its origin may not be clear due to extensive organ involvement. Both the malignant and benign forms have the same macroscopic appearance and share many common microscopic features as well [15]. The characteristic CT findings of pseudomyxoma peritonei are massive ascites or loculated fluid collections causing hepatic and mesenteric scalloping. These cystic and low-attenuation tumor masses ap-
Y. M a t s u o k a et al.: P s e u d o m y x o m a Peritonei
Fig. 1. Case 1. A C T scan of the upper a b d o m e n s h o w s Iobulaled indentations of the liver margin due to p s e u d o m y x o m a peritonei {arroyos). B Re-examination 4 m o n t h s after c h e m o t h e r a p y reveals multifocal calcifications around the liver {arrows). Fig. 2. Case 2. A C T scan 3 years after initial treatment for p s e u d o m y x o m a peritonei s h o w s large cystic m a s s e s of low-attenuation containing some punc~ate calcifications (arrows). B Follow-up study 2 years later d e m o n s t r a t e s marked progression in size and extent of calcifications. Fig. 3. Case 3. A and B. CT scans of the upper a b d o m e n and pelvis show loculated collections of p s e u d o m y x o m a peritonei associated with several tiny calcifications (arrows).
17
pear without lymphadenopathy and in the presence of intrinsically normal viscera [16]. Calcification in p s e u d o m y x o m a peritoneal is well known, but actually rare. To the best of our knowledge only 15 cases associated with calcification have been reported [114]. The sites of origin were the appendix in seven, ovary in six, and unknown in two cases. These calcifications were punctate or curvilinear. Our cases showed development of calcifications during or after chemotherapy, and serial CT studies demonstrated their progression. In three of the 15
18
previously reported cases, such calcifications were also revealed during chemotherapy [8, 10, 12]. Calcifications appeared after radiotherapy in one case [3]. Intervals of 4 months to 3 years after initial chemotherapy (average: 1 year 5 months) were noted for occurrence of calcifications in six cases including ours. Miller et al. [12] reported that calcifications in pseudomyxoma peritonei developed as a response to local-regional plus systemic chemotherapy, and were seen histologically only in focal areas of necrosis. It has been suggested that a chemical relationship may exist between the cartilage calcification in growing bone and calcification of intraperitoneal or tumor-associated mucin, both of which are very similar glycoproteins [17]. One of the relatively common causes of disseminated abdominal calcification is peritoneal metasta, sis from serous cystadenocarcinoma of the ovary, which often contains psammomatous calcifications. CT scans show them as tiny discrete calcifications peritoneal plaques in 40% of patients with peritoneal metastasis due to ovarian cancer [18]. Meconium peritonitis may also cause plaque-like or ring-like calcifications in the neonate [19]. Other isolated cases have been peritoneal mesothelioma [20], ruptured teratoma of the ovary [21], and serous or mucinous adenocarcimonas of the gastrointestinal tract [22, 23]. Our cases suggest that calcification is not infrequent in pseudomyxoma peritonei, especially during or after chemotherapy. However, such peritoneal calcifications are not characteristic for this entity and may occur with several other conditions as well.
References 1. Pugh DG. A roentgenologic aspect of pseudomyxoma peritonei. Radiology 1942;39:320-322 2. Weig CG, Koenig EC, Culver GJ. Pseudomyxoma peritonei: report of a case with unusual roentgen findings. A JR 1944;52:505-509 3. Papavasiliou CG. Calcification in secondary tumors of the spleen. Acta Radiol 1959:51:278-282 4. Bartholomew LG, Cain JC, Davis GD, Bulbufian AH. Scientific exhibit: misleading calcific shadows in the abdomen. Postgrad Med 1961 ;30:51-66
Y. Matsuoka et al.: Pseudomyxoma Peritonei 5. Noonan CD. Primary and secondary malignancy of the female reproductive system. Radiol Clin North Am 1965;3:375-387 6. Moncada R, Cooper RA, Garces M, Badrinath K. Calcified metastases from malignant ovarian neoplasm. Radiolo,~,y 1974;I 13:31-35 7. Balthazar EJ, Javors BR. Pseudomyxoma peritonei, clinical and radiographic features. Am J Gastroenterol 1977;68:5(11509 8. Douds HN, Pitt MJ. Calcified rims: characteristic but uncommon radiologic finding in pseudomyxoma peritonei. Gastrointest Radiol 1980;5:263-266 9. Mayes GB, Chuang VP, Fisher RG. CT of pseudomyxoma peritonei. A JR 1981 :136:807-808 10. Seale WB. Sonographic findings in a patient with pseudomyxoma peritonei. J Clin Ultrasound 1982;10:441-443 11. Fishman EK, Jones B, Magid D, Siegelman SS. lntraabdominal abscesses in pseudomyxoma peritonei: The value of computed tomography. J Comput Assist Tomogr 1983;7:449453 12. Miller DL, Udelsman R, Sugarbaker PH. Calcification of pseudomyxoma peritonei following intraperitoneal chemotherapy: CT demonstration. J Comput Assist Tomogr 1985:9:1123-1124 13. Dachman AH, Lichtenstein JE, Friedman AC. Mucocele of the appendix and pseudomyxoma peritonei. A JR 1985; 144:923-929 14. Takahashi M, Takekawa S, Suzuki K, Takahashi M, lshiwatari J. CT findings of pseudomyxoma peritonei. Jpn J Clin Radiol 1989;34:1453-1457 15. Yeh HC, Shafir MK, Slater G, Meyer RJ, Cohen BA, Geller SA. Ultrasonography and computed tomography in pseudomyxoma peritonei. Radiolo~o, 1984:153:507-510 16. Masaryk TJ, Chilcote WA. CT of pseudomyxoma peritonei: case report. Comptu Radiol 1984;8:43-47 17. Batlan LE. Calcification within the stomach wall in gastric malignancy. A JR 1954;72:788-794 18. Mitchell DG, Hill MC, Hill S, Zaloudek C. Serous carcinoma of the ovary: CT identification of metastatic calcified implants. Radiolo~r 1986;158:649-652 19. Pan EY, Chen LY, Yang JZ, Lee Z, Wang ZZ. Radiographic diagnosis of meconium peritonitis: a report of 200 cases including six fetal cases. Pediatr Radiol 1983;13:199-205 20. Stambaugh JE Jr, Burrows S, Jacoby J, Shivers H. Peritoneal mesothelioma associated with diffuse abdominal ossification and unusual presentation. J Med Soc N J 1977;74:689-693 21. Bfissler R, Theele CH, Labach H. Nodular and tumorlike gliomatosis peritonei with endometriosis caused by a mature ovarian teratoma. Pathol Res Pratt 1982;175:392-403 22. McCaughey WTE, Schryer MJP, Lin X, AI-Jabi M. Extraovarian pelvic serous tumor with marked calcification. Arch Pathol Lab Med 1986;110:78-80 23. Matsuoka Y, Itai Y, Ohtomo K, Nishikawa J, Sasaki Y. Calcification of peritoneal carcinomatosis from gastric carcinoma: CT demonstration. Eur J Radiol (in press) Received: June 4, 1991: accepted: J,ly I0, 1991
Gastrointestinal
Radiology 9 Springer-Verlag New York Inc. 1992
Pseudomyxoma Peritonei with Progressive Calcifications: CT Findings Yujiro Matsuoka, Kuni Ohtomo, Yuji Itai, Junichi Nishikawa, Koki Yoshikawa, and Yasuhito Sasaki Department of Radiology, University of Tokyo, Faculty of Medicine, Tokyo, Japan
Abstract. Development of abdominal calcifications due to pseudomyxoma peritonei is rare. The authors present three cases whereby computed tomographic (CT) studies during or after chemotherapy for pseudomyxoma peritonei demonstrated development and progression of punctate calcifications in the abdomen. The clinical and CT findings of these cases are presented together with a brief review of the pertinent literature. Key words: Abdomen, calcifications--Pseudomyxoma peritonei, CT diagnosis.
Pseudomyxoma peritoneal is characterized by mucinous ascites and implants throughout the abdominal cavity. The primary site is commonly the appendix or ovary. Calcification of pseudomyxoma peritonei is well known, but actually rare [1-14]. We report computed tomography (CT) of three cases showing development of progressive calcifications during or after chemotherapy.
Case Reports Case 1 A 40-year-old man Suffered from abdominal distension due to ascites. The cytology of the aspirated fluid was malignant and mucinous, suggesting pseudomyxoma peritonei. Initial CT demonstrated lobular hepatic indentations (Fig. IA). There was no .fiistory of surgery, and the cause of mucinous ascites was unknown. He was treated with intraperitoneal mitomycin C and intravenous fluorouracil (5-FU). The second CT 4 months later
Address offprint requests to: Yujiro Matsuoka, M.D., Department of Radiology, University of Tokyo, 7-3-1, Hongo, Bunkyoku, Tokyo 113, Japan
showed many punctate calcifications in the peritoneal cavity (Fig. IB). The calcifications became more prominent on the third CT 9 months after the initial diagnosis.
Case 2 A 61-year-old woman was diagnosed as having pseudomyxoma peritonei 5 years ago, following previous surgery for mucinous cystadenoma of the ovary. She had been treated with surgical resection of the recurrent tumor and chemotherapy for pseudomyxoma peritonei. The chemotherapy was both intraperitoneal and oral. CT showed many punctate calcifications in the peritoneal cavity 3 years after the first treatment (Fig. 2A). These calcifications increased within 1 year (Fig. 2B) and became much larger years later.
Case 3 A 73-year-old woman had surgery for mucinous cystadenocarcinoma of the ovary with pseudomyxoma peritonei. First CT showed peritoneal fluid collections without calcification. Seven months after treatment with intravenous cyclophosphamide (Endoxan), mitomycin C, and 5-FU, however, multifocal areas of small calcifications appeared in the peritoneum (Fig. 3A and B).
Discussion Pseudomyxoma peritoneal is essentially mucinous ascites; a rare complication of mucocele of the appendix and mucinous cystadenoma or cystadenocarcinoma of the ovary. Other primary sites are the colon, stomach, uterus, and pancreas, but its origin may not be clear due to extensive organ involvement. Both the malignant and benign forms have the same macroscopic appearance and share many common microscopic features as well [15]. The characteristic CT findings of pseudomyxoma peritonei are massive ascites or loculated fluid collections causing hepatic and mesenteric scalloping. These cystic and low-attenuation tumor masses ap-
Y. M a t s u o k a et al.: P s e u d o m y x o m a Peritonei
Fig. 1. Case 1. A C T scan of the upper a b d o m e n s h o w s Iobulaled indentations of the liver margin due to p s e u d o m y x o m a peritonei {arroyos). B Re-examination 4 m o n t h s after c h e m o t h e r a p y reveals multifocal calcifications around the liver {arrows). Fig. 2. Case 2. A C T scan 3 years after initial treatment for p s e u d o m y x o m a peritonei s h o w s large cystic m a s s e s of low-attenuation containing some punc~ate calcifications (arrows). B Follow-up study 2 years later d e m o n s t r a t e s marked progression in size and extent of calcifications. Fig. 3. Case 3. A and B. CT scans of the upper a b d o m e n and pelvis show loculated collections of p s e u d o m y x o m a peritonei associated with several tiny calcifications (arrows).
17
pear without lymphadenopathy and in the presence of intrinsically normal viscera [16]. Calcification in p s e u d o m y x o m a peritoneal is well known, but actually rare. To the best of our knowledge only 15 cases associated with calcification have been reported [114]. The sites of origin were the appendix in seven, ovary in six, and unknown in two cases. These calcifications were punctate or curvilinear. Our cases showed development of calcifications during or after chemotherapy, and serial CT studies demonstrated their progression. In three of the 15
18
previously reported cases, such calcifications were also revealed during chemotherapy [8, 10, 12]. Calcifications appeared after radiotherapy in one case [3]. Intervals of 4 months to 3 years after initial chemotherapy (average: 1 year 5 months) were noted for occurrence of calcifications in six cases including ours. Miller et al. [12] reported that calcifications in pseudomyxoma peritonei developed as a response to local-regional plus systemic chemotherapy, and were seen histologically only in focal areas of necrosis. It has been suggested that a chemical relationship may exist between the cartilage calcification in growing bone and calcification of intraperitoneal or tumor-associated mucin, both of which are very similar glycoproteins [17]. One of the relatively common causes of disseminated abdominal calcification is peritoneal metasta, sis from serous cystadenocarcinoma of the ovary, which often contains psammomatous calcifications. CT scans show them as tiny discrete calcifications peritoneal plaques in 40% of patients with peritoneal metastasis due to ovarian cancer [18]. Meconium peritonitis may also cause plaque-like or ring-like calcifications in the neonate [19]. Other isolated cases have been peritoneal mesothelioma [20], ruptured teratoma of the ovary [21], and serous or mucinous adenocarcimonas of the gastrointestinal tract [22, 23]. Our cases suggest that calcification is not infrequent in pseudomyxoma peritonei, especially during or after chemotherapy. However, such peritoneal calcifications are not characteristic for this entity and may occur with several other conditions as well.
References 1. Pugh DG. A roentgenologic aspect of pseudomyxoma peritonei. Radiology 1942;39:320-322 2. Weig CG, Koenig EC, Culver GJ. Pseudomyxoma peritonei: report of a case with unusual roentgen findings. A JR 1944;52:505-509 3. Papavasiliou CG. Calcification in secondary tumors of the spleen. Acta Radiol 1959:51:278-282 4. Bartholomew LG, Cain JC, Davis GD, Bulbufian AH. Scientific exhibit: misleading calcific shadows in the abdomen. Postgrad Med 1961 ;30:51-66
Y. Matsuoka et al.: Pseudomyxoma Peritonei 5. Noonan CD. Primary and secondary malignancy of the female reproductive system. Radiol Clin North Am 1965;3:375-387 6. Moncada R, Cooper RA, Garces M, Badrinath K. Calcified metastases from malignant ovarian neoplasm. Radiolo,~,y 1974;I 13:31-35 7. Balthazar EJ, Javors BR. Pseudomyxoma peritonei, clinical and radiographic features. Am J Gastroenterol 1977;68:5(11509 8. Douds HN, Pitt MJ. Calcified rims: characteristic but uncommon radiologic finding in pseudomyxoma peritonei. Gastrointest Radiol 1980;5:263-266 9. Mayes GB, Chuang VP, Fisher RG. CT of pseudomyxoma peritonei. A JR 1981 :136:807-808 10. Seale WB. Sonographic findings in a patient with pseudomyxoma peritonei. J Clin Ultrasound 1982;10:441-443 11. Fishman EK, Jones B, Magid D, Siegelman SS. lntraabdominal abscesses in pseudomyxoma peritonei: The value of computed tomography. J Comput Assist Tomogr 1983;7:449453 12. Miller DL, Udelsman R, Sugarbaker PH. Calcification of pseudomyxoma peritonei following intraperitoneal chemotherapy: CT demonstration. J Comput Assist Tomogr 1985:9:1123-1124 13. Dachman AH, Lichtenstein JE, Friedman AC. Mucocele of the appendix and pseudomyxoma peritonei. A JR 1985; 144:923-929 14. Takahashi M, Takekawa S, Suzuki K, Takahashi M, lshiwatari J. CT findings of pseudomyxoma peritonei. Jpn J Clin Radiol 1989;34:1453-1457 15. Yeh HC, Shafir MK, Slater G, Meyer RJ, Cohen BA, Geller SA. Ultrasonography and computed tomography in pseudomyxoma peritonei. Radiolo~o, 1984:153:507-510 16. Masaryk TJ, Chilcote WA. CT of pseudomyxoma peritonei: case report. Comptu Radiol 1984;8:43-47 17. Batlan LE. Calcification within the stomach wall in gastric malignancy. A JR 1954;72:788-794 18. Mitchell DG, Hill MC, Hill S, Zaloudek C. Serous carcinoma of the ovary: CT identification of metastatic calcified implants. Radiolo~r 1986;158:649-652 19. Pan EY, Chen LY, Yang JZ, Lee Z, Wang ZZ. Radiographic diagnosis of meconium peritonitis: a report of 200 cases including six fetal cases. Pediatr Radiol 1983;13:199-205 20. Stambaugh JE Jr, Burrows S, Jacoby J, Shivers H. Peritoneal mesothelioma associated with diffuse abdominal ossification and unusual presentation. J Med Soc N J 1977;74:689-693 21. Bfissler R, Theele CH, Labach H. Nodular and tumorlike gliomatosis peritonei with endometriosis caused by a mature ovarian teratoma. Pathol Res Pratt 1982;175:392-403 22. McCaughey WTE, Schryer MJP, Lin X, AI-Jabi M. Extraovarian pelvic serous tumor with marked calcification. Arch Pathol Lab Med 1986;110:78-80 23. Matsuoka Y, Itai Y, Ohtomo K, Nishikawa J, Sasaki Y. Calcification of peritoneal carcinomatosis from gastric carcinoma: CT demonstration. Eur J Radiol (in press) Received: June 4, 1991: accepted: J,ly I0, 1991
