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ovarian carcinoma [1 , unpublished data].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,

Intraperitoneal contrast infusion for assessment of intraperitoneal fluid dynamics.

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 rese...
434KB Sizes 0 Downloads 0 Views