State-of-the-Art-Bildgebung bei Peritonealkarzinose

Zusammenfassung

Bildgebende Verfahren sind von entscheidender Bedeutung bei der Bewertung von Patienten mit Verdacht auf eine peritoneale Metastasierung. Trotz erheblicher Fortschritte in der Schnittbildtechnologie bleibt die frühzeitige und adäquate Diagnostik der Peritonealkarzinose eine Herausforderung aufgrund der Vielfalt von Größe, Morphologie und Lokalisation der peritonealen Herde. Als neuer Therapieansatz bei peritonealer Metastasierung etabliert sich in spezialisierten Zentren die Peritonektomie kombiniert mit hyperthermer intraperitonealer Chemotherapie (HIPEC) als eine potenziell kurative Therapieoption bei ausgewählten Patienten. Entscheidend für die Prognose ist die möglichst komplette Zytoreduktion, die vom Ausmaß und der anatomischen Verteilung der peritonealen Tumorlast abhängt. Verschiedene bildgebende Verfahren werden zur Einschätzung der peritonealen Tumorausdehnung eingesetzt, um geeignete Patienten auszuwählen. Trotz bekannter Limitationen im Nachweis kleiner Läsionen und in der Diagnostik eines Dünndarmbefalls ist die kontrastangehobene MDCT aufgrund ihrer Genauigkeit, Verfügbarkeit und den geringen Kosten die Methode der Wahl in der Diagnostik der Peritonealkarzinose. Die MRT, insbesondere mit diffusionsgewichteten Sequenzen, und die FDG-PET/CT zeigen in aktuellen Studien überlegene Ergebnisse, bleiben aber aufgrund von Kosten, Untersuchungsdauer und Verfügbarkeit derzeit auf spezialisierte Zentren beschränkt. Alle Methoden zur Diagnostik der Peritonealkarzinose erfordern neben einem optimierten Untersuchungsprotokoll vor allem trainierte Radiologen, die mit den komplexen anatomischen Ausbreitungswegen und der variablen Morphologie peritonealer Läsionen vertraut sein sollten.

Abstract

Imaging studies are essential in the evaluation of patients with suspected or known peritoneal malignancy. Despite major advances in imaging technology in the last few years, the early and adequate detection of a peritoneal dissemination remains challenging because of the great variety in size, morphology and location of the peritoneal lesions. New therapeutic approaches in peritoneal-based neoplasms combining cytoreductive surgery and peritonectomy with hyperthermic intraoperative chemotherapy (HIPEC) suggest improved long-term survival, provided that a complete (macroscopic) cytoreduction is achieved. The preoperative radiological assessment of the extent and distribution of peritoneal involvement plays a vital role in the patient selection process. Despite its known limited accuracy in detecting small peritoneal lesions and the involvement of the small bowel/mesentery, contrast-enhanced MDCT remains the standard imaging modality in the assessment of peritoneal carcinomatosis. MRI, especially with diffusion-weighted images, and FDG-PET/CT are promising methods for the evaluation of peritoneal carcinomatosis with superior results in recent studies, but still have a limited role in selected cases because of high costs and limited availability. Generally, to obtain the most precise readings of peritoneal carcinomatosis, an optimized examination protocol and dedicated radiologists with a deep knowledge of peritoneal pathways and variable morphologies of peritoneal disease are required.

Key words

peritoneal carcinomatosis - MR imaging - PET-CT - CT - preoperative evaluation

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