Multimodality imaging appearances of malignant peritoneal disease, important differential diagnoses, and pitfall cases
Type:Educational Electronic Presentation
Authors: Samantha Fossey, Faye Cuthbert
Keywords:periton*, carcinomatosis
Educational objective


Primary serous peritoneal cancer (PPC) is a rare epithelial tumour that arises in the peritoneum and is thought to arise from extraovarian mesothelium that has Mullerian potential. PPC is histologically identical to surface epithelial ovarian cancer (which accounts for 90% of ovarian cancer) because tumour cells lie on the surface of the ovary or fallopian tubes and slough off and enter the peritoneal circulation. [1,2]

Peritoneal carcinomatosis can also result from metastatic spread of tumours from: the GI tract, ovary, lung, breast and uterus. Peritoneal disease can be seen in other benign conditions, therefore careful imaging assessment is paramount, and biopsy can profoundly alter management. [3]


The purpose of our educational exhibit is to:

Summarise and illustrate -

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Topic Review

The normal circulation of peritoneal fluid within the abdominal cavity and its regions of stasis

The peritoneum is a thin, translucent serosal membrane that covers the surface of the peritoneal cavity and its mesenteries. It’s purpose is to provide a surface over which the viscera can move, and as a site of fluid transport. [3]

Malignant cells are carried by peritoneal fluid throughout the abdomen and pelvis resulting in widespread metastases. The fluid follows a predictable circulation pathway from the pelvis to the diaphragm that is defined by the reflections of the peritoneum. [3]

Peritoneal fluid can flow upward from the pelvis due to pressure gradients in the abdomen which increase during inspiration (FIG 1). There are dependent recesses where the flow of... more

Figure 1: Coronal reformatted CT image demonstrating the circulation pathway of peritoneal fluid (arrows) from pelvis to abdomen that is defined by the reflections of the peritoneum.
Figure 2: Multiplanar CT images illustrating dependent recesses within the peritoneal cavity where flow may be interrupted and tumour cells can be deposited to form implants. (a) Coronal reformatted image shows subphrenic and subcapsular liver tumour deposits (black arrows). (b) Axial image shows tumour deposits in both paracolic gutters (black arrows). (c) Coronal reformatted image shows deposits in the ileocolic region (black arrow). (d) Sagittal reformatted image demonstrates tumour mass in the rectouterine space (black asterisk).


Peritoneal disease in women is not necessarily due to ovarian cancer, and imaging should be carefully assessed to look for clues in the differential. Imaging appearances of peritoneal carcinomatosis are predictable but can be diagnostically challenging because of its mimics. It is important to consider potential alternatives and biopsy, as optimal management differs with histology.



[1] Levy, A. Arnaiz, J. Shaw, J. et al. Primary Peritoneal Tumors: Imaging Features with Pathologic Correlation. Radiographics 2008;28:583-607.
[2] Pannu, H. Bristow, R. Montz, F. et al. Multidetector CT of Peritoneal Carcinomatosis from Ovarian Cancer.RadioGraphics 2003; 23:687–701
[3] Levy, A. Shaw, J. Sobin, L. Secondary Tumors and Tumorlike Lesions of the Peritoneal Cavity: Imaging Features with... more

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