Pseudomyxoma peritonei refers to intraperitoneal accumulation of a gelatinous ascites secondary to rupture of a mucinous tumour. The most common cause is a ruptured mucinous tumour of the appendix/appendiceal mucocoele 10.
Occasionally, mucinous tumours of the colon, rectum, stomach, pancreas and urachal tumours 9-10 are implicated. There is some ongoing contention as to whether primary ovarian tumours are a frequent source in their own right, or whether in these cases the appendix is the primary site and the ovarian lesion is metastatic 2-3.
The remarkable feature of pseudomyxoma peritonei is that this neoplastic, progressive process often arises from a seemingly benign or well differentiated primary tumour 3.
Pseudomyxoma peritonei may be divided into two pathological subtypes which have aetiological and prognostic significance 4.
- a peritoneal neoplasm composed largely of mucin associated with fibrosis with minimal cytologic atypia and mitoses
- the primary tumour is generally an adenoma
peritoneal mucinous carcinoma
- characterised by proliferative epithelium, glands, nests, or individual cells with marked cytologic atypia
- the primary is a mucinous adenocarcinoma
Not all cases fit neatly into these categories, and many patients have intermediate or discordant features.
However, a long term follow-up study 4 of 109 patients found 5 year survival rates were markedly different: 75% for the adenomucinosis group and 14% for the mucinous carcinoma group. The intermediate/discordant group 5 year survival was 50%.
It is typically characterised by loculated collections of fluid causing scalloping of abdominopelvic organs.
May show evidence of ascites with centrally displaced small bowel loops and scattered punctate or curvilinear calcifications.
- low attenuation, often loculated fluid throughout the peritoneum, omentum and mesentery.
- scalloping of visceral surfaces, particularly the liver 5
- scattered (curvilinear or punctate) calcifications may be frequently present 5
- tends to remain localised to the peritoneal cavity
- echogenic peritoneal masses or ascites with echogenic particles which (unlike other forms of particulate ascites such as haemoperitoneum or pus in the peritoneum) do not move 6
- the small bowel loops displaced medially.
- may show scalloping of the liver, spleen and at times other organs
Reported signal characteristics of the collections include 8
- T1: typically low signal
- T2: typically high signal
- T1 C+ (Gd): may show enhancement 12
- advanced cases may cause bowel obstruction
Treatment and prognosis
This is a progressive and often fatal disease. Recurrent bowel obstructions are commonly due to the fibrosis and adhesions.
Treatment is surgical debulking, followed by infusion of intraperitoneal chemotherapy.
General imaging differential considerations include:
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- 4- Ronnett BM, Yan H, Kurman RJ et-al. Patients with pseudomyxoma peritonei associated with disseminated peritoneal adenomucinosis have a significantly more favorable prognosis than patients with peritoneal mucinous carcinomatosis. Cancer. 2001;92 (1): 85-91. Cancer (link) - Pubmed citation
- 5- Yoo E, Kim JH, Kim MJ et-al. Greater and lesser omenta: normal anatomy and pathologic processes. Radiographics. 27 (3): 707-20. doi:10.1148/rg.273065085 - Pubmed citation
- 6- Hanbidge AE, Lynch D, Wilson SR. US of the peritoneum. Radiographics. 23 (3): 663-84. doi:10.1148/rg.233025712 - Pubmed citation
- 7- Ros PR, Mortele KJ. CT and MRI of the abdomen and pelvis, a teaching file. Lippincott Williams & Wilkins. (2006) ISBN:0781772370. Read it at Google Books - Find it at Amazon
- 8- Buy JN, Malbec L, Ghossain MA et-al. Magnetic resonance imaging of pseudomyxoma peritonei. Eur J Radiol. 1989;9 (2): 115-8. - Pubmed citation
- 9- Sugiyama K, Ito N. Mucinous cystadenocarcinoma of the urachus associated with pseudomyxoma peritonei with emphasis on MR findings. Magn Reson Med Sci. 2009;8 (2): 85-9. Magn Reson Med Sci (link) - Pubmed citation
- 10- Takeuchi M, Matsuzaki K, Yoshida S et-al. Imaging findings of urachal mucinous cystadenocarcinoma associated with pseudomyxoma peritonei. Acta Radiol. 2004;45 (3): 348-50. Acta Radiol (link) - Pubmed citation
- 11- Semelka RC. Abdominal-Pelvic MRI. Wiley-Blackwell. (2010) ISBN:0470487755. Read it at Google Books - Find it at Amazon
- 12- Eurorad teaching files : Case 1239