Annals of Surgical Oncology

, Volume 19, Issue 5, pp 1394–1401 | Cite as

Combined Diffusion-Weighted and Gadolinium-Enhanced MRI Can Accurately Predict the Peritoneal Cancer Index Preoperatively in Patients Being Considered for Cytoreductive Surgical Procedures

  • Russell N. Low
  • Robert M. Barone
Regional Cancer Therapies



To determine whether abdominal and pelvic magnetic resonance imaging (MRI) with diffusion-weighted and dynamic gadolinium-enhanced imaging can be used to accurately calculate the peritoneal cancer index (PCI) before surgery compared to the PCI tabulated at surgery.


Thirty-three patients underwent preoperative MRI followed by cytoreductive surgery for primary tumors of the appendix (n = 25), ovary (n = 5), colon (n = 2), and mesothelioma (n = 1). MRIs were retrospectively reviewed to determine the MRI PCI. These scores were then compared to PCI tabulated at surgery. Patients were categorized as having small-volume tumors (PCI 0–9), moderate-volume tumors (PCI 10–20), and large-volume tumors (PCI > 20). The respective anatomic site scores for both MRI and surgery were compared.


There was no significant difference between the MRI PCI and surgical PCI for the 33 patients (P = 0.12). MRI correctly predicted the PCI category in 29 (0.88) of 33 patients. Compared to surgical findings, MRI correctly predicted small-volume tumor in 6 of 7 patients, moderate-volume tumor in 3 of 4 patients, and large-volume tumor in 20 of 22 patients. MRI and surgical PCI scores were identical in 8 patients (24%). A difference of <5 was noted in 16 patients (49%) and of 5–10 in 9 patients (27%). Compared to surgical-site findings, MRI depicted 258 truly positive sites of peritoneal tumor, 35 falsely negative sites, 35 falsely positive sites, and 101 truly negative sites, with a corresponding sensitivity of 0.88, specificity of 0.74, and accuracy of 0.84.


Combined diffusion-weighted and gadolinium-enhanced peritoneal MRI accurately predicts the PCI before surgery in patients undergoing evaluation for cytoreductive surgery.


Magnetic Resonance Imaging Preoperative Magnetic Resonance Imaging Peritoneal Cancer Index Peritoneal Tumor Appendiceal Cancer 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Glenhen O, Gilly FN. Quantitative preoperative indicators of peritoneal surface malignancies: carcinomatosis, sarcomatosis, and peritoneal mesothelioma. Surg Oncol Clin N Am. 2003;12:649–71.CrossRefGoogle Scholar
  2. 2.
    Harmon RL, Sugarbaker PH. Prognostic indicators in peritoneal carcinomatosis from gastrointestinal cancer. Int Semin Surg Oncol. 2005;2:3.PubMedCrossRefGoogle Scholar
  3. 3.
    Sugarbaker PH, Jablonski KA. Prognostic features of 51 colorectal and 130 appendiceal cancer patients with peritoneal carcinomatosis treated by cytoreductive surgery and intraperitoneal chemotherapy. Ann Surg. 1995;221:124–32.PubMedCrossRefGoogle Scholar
  4. 4.
    Sugarbaker PH, Ronnett BM, Archer A, et al. Pseudomyxoma peritonei syndrome. Adv Surg. 1997;30:233–80.Google Scholar
  5. 5.
    Sugarbaker PH. Results of treatment of 385 patients with peritoneal surface spread of appendiceal malignancy. Ann Surg Oncol. 1999;6:727–31.PubMedCrossRefGoogle Scholar
  6. 6.
    Vaira M, Cioppa T, D’Amico S, et al. Peritoneal colorectal carcinomatosis treated with surgery and perioperative intraperitoneal chemotherapy: retrospective analysis of 523 patients from a multicentric French study. J Clin Oncol. 2010;28:63–8.CrossRefGoogle Scholar
  7. 7.
    Glehen O, Kwiatkowski F, Sugarbaker PH, et al. Cytoreductive surgery combined with perioperative intraperitoneal chemotherapy for the management of peritoneal carcinomatosis from colorectal cancer: a multi-institutional study. J Clin Oncol. 2005;22:3284–92.CrossRefGoogle Scholar
  8. 8.
    Jacquet P, Jelinek JS, Sugarbaker PH. Abdominal computed tomographic scan in the selection of patients with mucinous peritoneal carcinomatosis for cytoreductive surgery. J Am Coll Surg. 1995;181:530–8.PubMedGoogle Scholar
  9. 9.
    Low RN, Barone RM, Gurney JM. Mucinous appendiceal neoplasms: preoperative MR staging and classification compared with surgical and histopathologic findings. Am Roentgenol. 2008;190:656–65.CrossRefGoogle Scholar
  10. 10.
    Coakley FV, Choi PH, Gougoutas CA, et al. Peritoneal metastases: detection with spiral CT in patients with ovarian cancer. Radiology. 2002;223:495–500.PubMedCrossRefGoogle Scholar
  11. 11.
    Low RN, Barone RM, Lacey C, Sigeti JS, Alzate GD, Sebrechts CP. Peritoneal tumor: MR imaging with dilute oral barium and intravenous gadolinium-containing contrast agents compared with unenhanced MR imaging and CT. Radiology. 1997;204:513–20.PubMedGoogle Scholar
  12. 12.
    Koh JL, Tan TD, Glenn D, Morris DL. Evaluation of preoperative computed tomography in estimating peritoneal cancer index in colorectal peritoneal carcinomatosis. Ann Surg Oncol. 2009;16:327–33.PubMedCrossRefGoogle Scholar
  13. 13.
    Low RN, Saleh F, Song SYT, et al. Treated ovarian cancer: comparison of MR imaging with serum CA-125 level and physical examination—a longitudinal study. Radiology. 1999;211:519–28.PubMedGoogle Scholar
  14. 14.
    Low RN, Duggan B, Barone RM, Saleh F, Song SYT. Treated ovarian cancer: MR imaging, laparotomy reassessment, and serum CA-125 values compared with clinical outcome at 1 year. Radiology. 2005;235:918–26.PubMedCrossRefGoogle Scholar
  15. 15.
    Low RN, Gurney J. Diffusion-weighted MRI (DWI) in the oncology patient: value of breathhold DWI compared to unenhanced and gadolinium-enhanced MR. J Magn Reson Imaging. 2007;25:848–58.PubMedCrossRefGoogle Scholar
  16. 16.
    Low RN, Sebrechts CP, Barone RM, Muller W. Diffusion-weighted MRI of peritoneal tumors: comparison with conventional MRI and surgical and histopathologic findings—a feasibility study. Am J Roentgenol. 2009;193:461–70.CrossRefGoogle Scholar
  17. 17.
    Sugarbaker PH. Peritonectomy procedures. Surg Oncol Clin N Am. 2003;12:703–27.PubMedCrossRefGoogle Scholar
  18. 18.
    Yan TD, Sim J, Morris DL. Selection of patients with colorectal peritoneal carcinomatosis for cytoreductive surgery and perioperative intraperitoneal chemotherapy. Ann Surg Oncol. 2009;14:1807–17.CrossRefGoogle Scholar
  19. 19.
    Esquivel J, Sugarbaker PH. Second-look surgery in patients with peritoneal dissemination from appendiceal malignancy: analysis of prognostic factors in 98 patients. Ann Surg. 2001;234:198–205.PubMedCrossRefGoogle Scholar
  20. 20.
    Dawson LE, Russell AH, Tong D, et al. Adenocarcinoma of the sigmoid colon: sites of initial dissemination and clinical patterns of recurrence following surgery alone. J Surg Oncol. 1983;22:95–9.PubMedCrossRefGoogle Scholar
  21. 21.
    Chu DZ, Lang NP, Thompson C, et al. Peritoneal carcinomatosis in nongynecologic malignancy: a prospective study of prognostic factors. Cancer. 1989;63:364–7.PubMedCrossRefGoogle Scholar
  22. 22.
    Jayne DG, Fook S, Loi C, et al. Peritoneal carcinomatosis from colorectal cancer. Br J Surg. 2002;89:1545–50.PubMedCrossRefGoogle Scholar
  23. 23.
    Sugarbaker PH, Zhu BW, Sese GB, Shmookler B. Peritoneal carcinomatosis from appendiceal cancer: results in 69 patients treated by cytoreductive surgery and intraperitoneal chemotherapy. Colon Rectum. 1993;36:323–9.CrossRefGoogle Scholar
  24. 24.
    Esquivel J, Sticca R, Sugarbaker P, et al. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in the management of peritoneal surface malignancies of colonic origin: a consensus statement. Ann Surg Oncol. 2007;14:128–33.PubMedGoogle Scholar
  25. 25.
    Esquivel J, Chua TC, Stojadinovic A, et al. Accuracy and clinical relevance of computed tomography scan interpretation of peritoneal cancer index in colorectal cancer peritoneal carcinomatosis: a multi-institutional study. J Surg Oncol. 2010;102:565–70.PubMedCrossRefGoogle Scholar
  26. 26.
    Knorr C, Reingruber B, Meyer T, et al. Peritoneal carcinomatosis of colorectal cancer: incidence, prognosis, and treatment modalities. Int J Colorectal Dis. 2004;19:181–7.PubMedCrossRefGoogle Scholar
  27. 27.
    Sugarbaker PH. Revised guidelines for second-look surgery in patients with colon and rectal cancer. Clin Transl Oncol. 2010;12:621–8.PubMedCrossRefGoogle Scholar
  28. 28.
    Sugarbaker PH. Surgical responsibilities in the management of peritoneal carcinomatosis. J Surg Oncol. 2010;101:713–24.PubMedCrossRefGoogle Scholar
  29. 29.
    Verwaal VJ, Bruin S, Boot H, et al. 8 yr follow-up of randomized trial: cytoreductive surgery and hyperthermic chemotherapy versus systemic chemotherapy in patients with peritoneal carcinomatosis of colorectal cancer. Ann Surg Oncol. 2008;15:2426–32.PubMedCrossRefGoogle Scholar
  30. 30.
    Sugarbaker PH. New standard of care for epithelial neoplasms and pseudomyxoma peritonei syndrome? Lancet Oncol. 2006;7:69–76.PubMedCrossRefGoogle Scholar
  31. 31.
    Baratti D, Dusamura S, Nonaka D, et al. Pseudomyxoma peritonei: clinical pathological and biological factors in patients treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC). Ann Surg Oncol. 2008;15:526–34.PubMedCrossRefGoogle Scholar
  32. 32.
    Vaira M, Cioppa T, De Marco G, et al. Management of pseudomyxoma peritonei by cytoreduction + HIPEC (hyperthermic intraperitoneal chemotherapy): results analysis of a twelve-year experience. In Vivo. 2009;23:639–44.PubMedGoogle Scholar
  33. 33.
    Winder T, Lenz HJ. Mucinous adenocarcinomas with intra-abdominal dissemination: a review of current therapy. Oncologist. 2010;8:836–44.CrossRefGoogle Scholar
  34. 34.
    Sugarbaker PH, Bijelic L, Chang D, Yoo D. Neoadjuvant FOLFOX chemotherapy in 34 consecutive patients with mucinous peritoneal carcinomatosis of appendiceal origin. J Surg Oncol. 2010;102:576–81.PubMedCrossRefGoogle Scholar
  35. 35.
    Chua TC, Yan TD, Deraco M, Glehen O, Moran BJ, Sugarbaker PH. Multi-institutional experience of diffuse intra-abdominal multicystic peritoneal mesothelioma. Br J Surg. 2011;98:60–4.PubMedCrossRefGoogle Scholar
  36. 36.
    Sugarbaker PH. Five reasons why cytoeductive surgery plus hyperthermic intraperitoneal chemotherapy must be regarded as the new standard of care for diffuse malignant peritoneal mesothelioma. Ann Surg Oncol. 2010;17:1710–2.PubMedCrossRefGoogle Scholar
  37. 37.
    Zappa L, Savady R, Sugarbaker PH. Gastric perforation following cytoreductive surgery with perioperative intraperitoneal chemotherapy. J Surg Oncol. 2010;101:634–6.PubMedCrossRefGoogle Scholar
  38. 38.
    Helm CW, Richard SD, Pan J, et al. Hyperthermic intraperitoneal chemotherapy in ovarian cancer: first report of the HYPER-O registry. Int J Gynecol Cancer. 2010;20:61–9.PubMedCrossRefGoogle Scholar
  39. 39.
    Yonemura Y, Tsukiyama G, Miyata R, et al. Indication of peritonectomy for peritoneal dissemination. Gan To Kagaku Ryoho. 2010;37:2306–11.PubMedGoogle Scholar
  40. 40.
    Berrington de Gonzalez A, Darby S. Risk of cancer from diagnostic x-rays: estimates for the UK and 14 other countries. Lancet. 2004;363:345–51.Google Scholar
  41. 41.
    Brenner D, Elliston C, Hall E, Berdon W. Estimated risks of radiation-induced fatal cancer from pediatric CT. Am J Roentgenol. 2001;176:289–96.Google Scholar

Copyright information

© Society of Surgical Oncology 2012

Authors and Affiliations

  1. 1.Department of RadiologySharp Memorial HospitalSan DiegoUSA
  2. 2.Department of Surgical OncologySharp Memorial HospitalSan DiegoUSA

Personalised recommendations