Downloaded from www.ajronline.org by 117.253.240.20 on 11/08/15 from IP address 117.253.240.20. Copyright ARRS. For personal use only; all rights reserved
221
Intraperitoneal Contrast Infusion for Assessment lntraperitoneal Fluid Dynamics
of
For patients undergoing intraperitoneal (“belly bath”) chemotherapy, it is useful to the distribution of infusion fluid. For this reason, 10 patients were examined by computed tomography (CT) after intraperitoneal instillation of dialysate mixed with
N. Reed Dunnick,1 Roy B. Jones,2 John L. Doppman,1 James Speyer,2 and Charles E. Myers2
verify
water
soluble in two
and
contrast
patients
Intraperitoneal promising
material.
filling
The
defects,
infusion
extent
of intraperitoneal
presumably
of methotrexate
pharmacologic
entire from
is administered
peritoneal the
in high
surface
peritoneal
should
cavity
and
for
volume
treating of drug
peritoneal
liter),
the drugs
or totally
volume
removed
Since
these
patients
have
extensive
surgery
and/or
prevent
uniform
intraperitoneal
instillation
is reduced.
peritoneoscopy,
fluid
Computed
abdominal
cavity.
distribution
tomography
may
and
liver
examination
before
low [2, 3]. tumor with
may
be present.
of the absorbed
by the
the therapeutic (CT)
When
exposure
are poorly
metastases
adhesions
from
is based
passage into the systemic circulation plasma, concentrations remain Thus, high concentrations of drug may be delivered to intraperitoneal relatively small risk of significant systemic toxicities. previous
offers
metastases
of this technique
(1 .5-3
Since
partly
assessed,
identified.
in high
in the
solution
was
were
peritoneal
The success
be possible. are
tumor,
or 5-fluorouracil
advantages
ovarian carcinoma [1 , unpublished data]. on maintaining high local concentration
the drug
distribution
representing
have
had
If adhesions
effect after
of drug intraperi-
toneal infusion of water soluble contrast material has been helpful in assessing the extent of fluid distribution. In addition, this method allows visualization of peritoneal metastases often difficult to detect by conventional techniques. The results of these examinations are reported. Received February 2, 1979; accepted
April 23,
1979.
Department
of Diagnostic
Radiology,
Building
Room 6S211, NIH, The clinical Center, Bethesda, MD 20014. Address reprint requests to N. 10,
R.
Dunnick. 2
Clinical
Cancer
Pharmacology
Treatment,
Branch,
National Cancer MD
The Clinical Center. Bethesda, AJR 133:221-223, 0361 -803X/79/
August 1332-0221
Division
of
Institute,NIH. 20014
1979 $00.00
Subjects
and
Ten patients,
Methods 22-64
water soluble contrast
years
material.
old, were
examined
with
CT after
Nine women had carcinoma
intraperitoneal
infusion
of
of the ovary and one man had
malignant melanoma. All 1 0 patients had peritoneal metastases or malignant effusions verified by biopsy during peritoneoscopy or laparotomy, and were subsequently treated with intraperitoneal infusions of methotrexate or 5-fluorouracil. The CT scans were performed on an EMI 5005 with 18 sec scan time. Before CT, the
DUNNICK
Downloaded from www.ajronline.org by 117.253.240.20 on 11/08/15 from IP address 117.253.240.20. Copyright ARRS. For personal use only; all rights reserved
222
I
ET AL.
AJR:133,
August
1979
:
Fig.
1 -After
intraperitoneal
contrast.
A,
Normal
distribution
in upper
abdomen. B, Contrast material seen well into pelvis surrounding loops of bowel. C, Same patient as in A, 9 months later. Adhesions prevent complete intraperitoneal distribution over surface of liver. D, Intraperitoneal filling defects in right upper quadrant (arrows) believed to represent studding of peritoneal surface from metastases. E, Filling defect (arrow) enlarged on three successive examinations over 7 weeks.
patients were infused with 1,500-3,000 ml balanced dialysate (1 .5% Impersol, Abbott Labs, Chicago, III.) fluid containing 75 ml of 25% Hypaque (Winthrop Labs, N.Y.) per liter dialysate through an indwelling Tenckoff peritoneal dialysis catheter [4]. The abdomen
was gently massaged dialysate. The dialysate
to encourage complete distribution of the was withdrawn after scanning. The largest volume of dialysate that each patient could tolerate without symptoms was administered. One patient developed culture proven Pseu-
August
AJR:133,
INTRAPERITONEAL
1979
peritonitis
domonas aeruginosa successfully eradicated
plications
24 hr later.
with intravenous
DISTRIBUTION
The infection
gentamicin.
No other
was com-
were observed.
OF
CONTRAST
For this technique to be successful the entire peritoneal surface must be exposed to dialysate. CT examination after infusion of contrast material demonstrates the completeness of intraperitoneal
Downloaded from www.ajronline.org by 117.253.240.20 on 11/08/15 from IP address 117.253.240.20. Copyright ARRS. For personal use only; all rights reserved
Results
The intraperitoneal space was completely demonstrated in all patients. The contrast-containing dialysis fluid extended over the surface of the liver, around the spleen, into the lesser sac, and delineated the anterior extent of the retroperitoneal space (fig. 1 A). Contrast material could also be appreciated between loops of bowel and mesentery in the midabdomen and extending into the pelvis and pouch of Douglas inferiorly (fig. 1 B). In eight patients the distribution appeared complete and unimpaired. In one, there was incomplete visualization of contrast over the dome of the liver. In another, but repeat
stricted
intraperitoneal examination
distribution
Two
patients
believed
1 0 weeks
metastatic
filling tumor.
defects In both
laparotomy 6 weeks after in this location. At postmortem
after CT the liver was virtually
second
successive
1 C).
intraperitoneal
that cases
we the
were well defined and seemed to arise from surface in the right upper quadrant (fig. 1 D).
In one patient, metastatic tumor In the
(fig. had
represented
filling defects the peritoneal
distribution was normal initially, 9 months later demonstrated re-
patient
examinations
the
filling
over
defect
7 weeks
CT
confirmed examination
encased enlarged
(fig.
distribution.
CT
is a sensitive
method
of
detecting intraperitoneal fluid and the addition of contrast material is not necessary to demonstrate its distribution in the upper abdomen. In the midabdomen and pelvis where fluid-filled tions,
bowel the
use
loops
may
of contrast
assume material
a variety in the
of configura-
dialysate
is very
valuable. In addition, intraperitoneal fluid is much more readily distinguished from tumor masses when contrast material is added to the dialysate. Tumor masses on the peritoneal surface may not be demonstrable with any other radiologic method. Such demonstration may be valuable in the assessment of the effectiveness of treatment. Many tumor masses will remain undetected by this technique, particularly tumor attached to the bowel or mesentery. In addition, tumor masses that mimic the appearance of fluid-filled bowel may go undetected. It is possible that this problem could be overcome by flooding the bowel with contrast material at the time of examination. We conclude that CT scanning of the abdomen after administration of contrast-containing dialysate is a valuable adjunct for evaluation
with tumor.
223
MATERIAL
of patients
undergoing
intraperitoneal
chemotherapy.
on three
1 E).
REFERENCES 1 . Jones DeVita
Discussion
Tumors such as those arising from the ovary, colon, breast may break into the peritoneal space and are prone
or to
extensive
in
intraperitoneal
dissemination
that
often
results
studding of the peritoneal surface. Systemic chemotherapy required to control extensive peritoneal tumor may result in unacceptable toxicity. The development of the belly bath” technique for intraperitoneal infusion of chemotherapeutic agents allows delivery of high concentrations of drug to the tumor and yet avoids high plasma concentrations of drug which correlate with systemic toxicity [2, unpublished data].
RB, Myers CE, Guarino AM, Dedrick AL, Hubbard SM, VT: High volume intraperitoneal chemotherapy (‘ ‘belly bath’ ‘) for ovarian cancer. Cancer Chemother Pharmaco! 1: 161-166, 1978
2. Dedrick
AL, Myers CE, Bugnay PM, DeVita VT: Pharmacokinetic
rationale for peritoneal drug administration in treatment of ovarian cancer. Cancer Treat Rep 62:1-11,1978 3. Myers CE, Jones RB, Londer H, Hubbard SM, Brennan MF,
‘
Balow
4.
VT: Pharmacology
of
high dose methotrexate (MTX) administered via peritoneal alysis (abstr). Proc Am Soc Clin Oncol 1 9 : 390, 1978
di-
Tenckhoff
access 1968
JE, Dedrick
H,
device.
AL, Ozols
Schechter
Trans
R, DeVita
H: A bacteriologically
Amer
Soc Artif
Intern
safe
Org
peritoneal
14:181-187,