Case Author(s): David A. Hillier, M.D., Ph.D. and Jerold Wallis, M.D. , . Rating: #D3, #Q3

Diagnosis: Peritoneal cavity scintigraphy

Brief history:

53 year-old woman with a history of colon cancer.

Images:

Anterior images centered over the abdomen. What is this study, and why is it being performed?

View main image(ps) in a separate image viewer

View second image(ct). Computed tomography of abdomen/pelvis

View third image(ps). Selected early and late images from the main image set, shown enlarged and rescaled.

Full history/Diagnosis is available below

Diagnosis: Peritoneal cavity scintigraphy

Full history:

53 year-old woman with a history of cecal colon cancer with direct extension to the left ovary. Intraperitoneal chromic phosphate (P-32) therapy is planned.

Radiopharmaceutical:

Peritoneal cavity scintigraphy, 1.1 mCi Tc-99m sulfur colloid and 5.4 mCi Tc-99m sulfur colloid via peritoneal catheters

Findings:

1. Peritoneal cavity scintigraphy:

- Free flow in the peritoneal cavity through both peritoneal percutaneous peritoneal catheters.

2. Computed tomography of the abdomen and pelvis:

- Large cystic pelvic mass with multiple nodular septations, 14x16x18 cm.

Discussion:

Phosphorus-32 is a pure beta emitter that finds use for local radiation therapy. Intraperitoneal P-32 therapy may be performed to treat diffuse peritoneal mestastases. Prior to instillation of P-32, verification that the catheters are propery placed and have no loculation is important. Prior studies have shown a significant increase if complication rate if chromic phosphate therapy is conducted in a loculated space.

Contrast may also be used to assess the catheter, but is not as easy to interpret and thus entails more risk. Imaging to rule out loculation is best performed with Tc-99m sulfur colloid to assess intraperitoneal distribution. This can then be followed by infusion of chromic phosphate. Approximately 1 liter of ascites fluid was left in place (in one study) when the chromic phosphate is instilled to allow homogeneous distribution.

Note that P-32 is available in two forms: the chromic phosphate intended for intraperitoneal administration, and a soluble form used in much smaller doses for intravenous administration to treat polycythemia vera. Mistaken use of the soluble form for large dose intraperitoneal treatment would likely result in death of the patient, due to diffusion of the tracer into the bloodstream and subsequent bone marrow suppression.

References:

McGowan L. Adjuvant intraperitoneal chromic phosphate therapy in a woman with earlly ovarina carcinoma an pelvic infection with resulting catastrophic complications. Clin Nucl Med. 19, 696-698. 1994.

Tulchinsky M and Eggli D. Intraperitoneal distribution imaging prior to chromic phosphate (P-32) therapy in ovarian cancer patients. Clin Nucl Med. 19, 43-48. 1994

Differential Diagnosis List

Free flow of tracer in the peritoneal cavity is seen, ruling out loculation of the catheters.

ACR Codes and Keywords:

References and General Discussion of Peritoneal Shunt Scintigraphy (Anatomic field:Gasterointestinal System, Category:Neoplasm, Neoplastic-like condition)

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Case number: ps002

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