DOI: 10.1148/rg.232025081
(Radiographics. 2003;23:457-473.)
© RSNA, 2003
Mesenteric Neoplasms: CT Appearances of Primary and Secondary Tumors and Differential Diagnosis1
Sheila Sheth, MD,
Karen M. Horton, MD,
Melissa R. Garland, MS and
Elliot K. Fishman, MD
1 From the Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medical Institutions, 600 N Wolfe St, HAL B176D, Baltimore, MD 21287. Presented as an education exhibit at the 2001 RSNA scientific assembly. Received April 17, 2002; revision requested July 16 and received August 22; accepted August 23. Address correspondence to S.S. (e-mail: ssheth@jhmi.edu).
 |
Abstract
|
|---|
Computed tomography (CT) remains the optimal imaging modality for diagnosing tumors in the mesentery. Although primary neoplasms arising from the mesenchymal tissues of the mesentery are rare, the small bowel mesentery is a major avenue for the dissemination of tumor within the peritoneal cavity. Tumors spread to the mesentery by four major routes: (a) direct extension, commonly seen with carcinoid tumor of the small intestine as well as intraabdominal cancers such as pancreatic and colon cancer; (b) lymphatic dissemination of lymphoma and some epithelial malignancies; (c) hematogenic spread resulting in embolic metastases to the small intestinal wall, usually seen in melanoma and breast cancer; and (d) seeding through the peritoneum from ovarian and gastrointestinal malignancies as well as some lymphomas. Although percutaneous imaging-guided or surgical biopsy is often necessary to guide management, analysis of CT features along with the clinical history may be useful in differentiating mesenteric tumors from infectious, inflammatory, or vascular processes affecting the mesentery. The article presents the characteristic appearances of primary and secondary mesenteric neoplasms at CT and offers a rational approach to the differential diagnosis of mesenteric masses depicted at CT.
© RSNA, 2003
Index Terms: Mesentery, CT, 792.12112 • Mesentery, neoplasms, 792.30
|
LEARNING OBJECTIVES FOR TEST 5
|
|---|
After reading this article and taking the test, the reader will be able to:
- Describe the patterns of spread of tumor in the abdominal cavity.
- Identify the CT appearances of common and rare mesenteric neoplasms.
- Discuss a rational approach to the differential diagnosis of mesenteric lesions.
|
Introduction
|
|---|
The small bowel mesentery is a broad, fan-shaped fold of peritoneum that suspends the loops of the small intestine from the posterior abdominal wall. The two layers of peritoneal reflection forming the mesentery contain a variable amount of fat through which run the major arteries, veins, and lymphatics of the small intestine (Fig 1). Its root, a bare area that is contiguous with the pararenal spaces, extends diagonally from its origin at the ligament of Treitz inferiorly and to the right toward the ileocecal valve.
View larger version (152K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 1. Normal appearance of the small bowel mesentery in a potential renal donor. Coronal contrast material-enhanced computed tomographic (CT) image shows the mesenteric vessels running through the mesenteric fat. A small node is present (arrow).
|
|
Primary tumors arising in the mesentery are relatively rare (1–3). On the other hand, the mesentery is a frequent avenue of spread for malignant neoplasms through the peritoneal cavity and between the peritoneal spaces and the retroperitoneum (2,3). Patients with mesenteric neoplasms usually present with nonspecific symptoms of abdominal pain, weight loss, a palpable abdominal mass, or diarrhea. CT plays a critical role in achieving an accurate diagnosis of these neoplasms to guide patient management.
The objectives of this article are to illustrate the appearances of primary and secondary mesenteric neoplasms as depicted at CT, including the patterns of tumor spread to the mesentery, and to discuss important aspects of the differential diagnosis of these tumors as well as potential pitfalls.
|
Primary Mesenteric Neoplasms
|
|---|
Primary tumors arising from the mesentery are rare. In their review of a large series of patients with mesenteric abnormalities seen at CT, Whitley et al (3) found 101 cases of mesenteric neoplasms, and all but one were metastatic lesions. Most primary lesions are mesenchymal in origin, and the majority are histologically benign (1).
Desmoid Tumor
Desmoid tumors are rare, locally aggressive, nonencapsulated masses resulting from a benign proliferation of fibrous tissue. Abdominal desmoids can occur sporadically and develop anywhere in the abdomen, including the musculature of the abdominal wall, the retroperitoneum, and the pelvis. However, desmoids forming in the mesentery are especially common in patients with familial adenomatous polyposis (Gardner syndrome), occurring in 9%–18% of cases (4–6). In fact, abdominal desmoids are responsible for a considerable number of life-threatening complications in these patients. Almost 75% of these tumors develop in patients who have undergone previous abdominal surgery (7).
Abdominal desmoids can be solitary or multiple. Their CT manifestations are variable. Intramuscular desmoids tend to have well-defined or partially well-defined borders (7). Mesenteric tumors appear as soft-tissue masses with well-demarcated or poorly defined borders, strands radiating into the adjacent mesenteric fat (8), or a "whorled appearance" of fibrosis growing into the mesenteric fat (7). Infiltration into adjacent organs or growth into the abdominal wall musculature of the psoas muscle is not uncommon. Most mesenteric desmoids are isoattenuating relative to muscle (Fig 2), although large lesions may display areas of low attenuation caused by necrosis (Fig 3).
View larger version (127K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 2a. Desmoid tumor in a 42-year-old man with abdominal pain. (a) Axial contrast-enhanced CT image of the lower abdomen shows a 5-cm soft-tissue mass in the mesentery (arrow). The attenuation of the mass is similar to that of the psoas muscles. (b) Coronal reformatted image demonstrates that the mesenteric vessels are displaced but not encased by the mass. Histologic analysis of the surgical specimen yielded the diagnosis of desmoid tumor.
|
|
View larger version (162K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 2b. Desmoid tumor in a 42-year-old man with abdominal pain. (a) Axial contrast-enhanced CT image of the lower abdomen shows a 5-cm soft-tissue mass in the mesentery (arrow). The attenuation of the mass is similar to that of the psoas muscles. (b) Coronal reformatted image demonstrates that the mesenteric vessels are displaced but not encased by the mass. Histologic analysis of the surgical specimen yielded the diagnosis of desmoid tumor.
|
|
View larger version (156K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 3a. Desmoid tumor in a 29-year-old woman with Gardner syndrome and recent onset of abdominal pain. (a) Axial contrast-enhanced CT image shows a 4 x 7-cm soft-tissue mass involving the left rectus abdominis muscle (arrow). The mass is nearly isoattenuating relative to muscle. (b) Contrast-enhanced axial CT image obtained 11 cm higher shows an intraabdominal soft-tissue mass with a central area of lower attenuation (arrow). Histologic findings confirmed the diagnosis of desmoid tumors.
|
|
View larger version (148K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 3b. Desmoid tumor in a 29-year-old woman with Gardner syndrome and recent onset of abdominal pain. (a) Axial contrast-enhanced CT image shows a 4 x 7-cm soft-tissue mass involving the left rectus abdominis muscle (arrow). The mass is nearly isoattenuating relative to muscle. (b) Contrast-enhanced axial CT image obtained 11 cm higher shows an intraabdominal soft-tissue mass with a central area of lower attenuation (arrow). Histologic findings confirmed the diagnosis of desmoid tumors.
|
|
CT is useful in planning surgical resection and predicting prognosis. Large size (>10 cm); multi-plicity; and extensive infiltration, tethering, and encasement of small bowel loops and entrapment of the ureters are poor prognostic signs (7).
Other Primary Mesenteric Tumors
These neoplasms are quite uncommon. Case reports of a variety of mesenchymal tumors of the mesentery including lipomas, schwannomas, smooth muscle tumors (Fig 4), and sarcomas are scattered through the literature (9–12).
View larger version (125K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 4. Gastrointestinal autonomic nerve tumor in a 48-year-old woman with explosive diarrhea. Axial contrast-enhanced CT image of the midabdomen shows a 6-cm intensely enhancing mesenteric mass (arrows). Tumor enhancement is comparable with the nodular enhancement of a known hepatic giant hemangioma (arrowhead). There is no intestinal wall thickening or beading of the surrounding mesentery. Pathologic evaluation of the surgical specimen revealed a spindle cell tumor with features of a gastrointestinal autonomic nerve tumor.
|
|
Differential Diagnosis
Carcinoid tumor metastatic to the mesentery and sclerosing mesenteritis can mimic primary mesenteric neoplasm at CT.
Carcinoid Tumor.—
Carcinoid tumors originate in the intestines with secondary spread to the mesentery by direct extension or lymphatic spread and will be discussed later. However, as the primary intestinal mass is often small and difficult to detect at CT, the mesenteric tumor is usually the dominant imaging finding.
Sclerosing Mesenteritis.—
Sclerosing mesenteritis is a rare inflammatory condition of unknown cause that affects the root of the mesentery. The mesenteric fat is involved with a variable amount of inflammation, fatty necrosis, and fibrosis.
When the inflammation predominates (so-called mesenteric panniculitis), patients generally present with acute pain. On CT images, mesenteric panniculitis appears as a focal area of increased attenuation within the mesenteric fat surrounded by a pseudocapsule (Fig 5), an appearance that has been described as "the misty mesentery" (13). Areas of fibrosis within the inflamed fat appear as linear bands of soft-tissue attenuation (14).
View larger version (132K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 5. Mesenteric panniculitis in an 80-year-old woman with abdominal pain. Axial contrast-enhanced CT image of the midabdomen shows increased attenuation of the fat surrounding the mesenteric vessels (solid arrow). Note the pseudocapsule (open arrow) and the perivascular halo (arrowhead). This appearance is characteristic of mesenteric panniculitis.
|
|
In the chronic form or retractile mesenteritis, the fibrosis predominates and the disease manifests itself as large masses of soft-tissue attenuation that may contain calcifications (Fig 6). Some masses are poorly defined, with whiskers of soft-tissue thickening extending into the adjacent fat (14). Involvement of parenchymal organs such as the pancreas has been described (15).
View larger version (136K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 6a. Sclerosing mesenteritis in a 70-year-old man with recurrent rectal bleeding. (a) Axial contrast-enhanced CT image of the midabdomen shows an 8.5 x 3-cm soft-tissue mass at the root of the mesentery (solid arrows). The lesion contains coarse calcifications (open arrow). Mesenteric varices are present (arrowheads). (b) Axial contrast-enhanced CT image obtained 3 cm above a shows encasement of the superior mesenteric artery (open arrow) and near occlusion of the superior mesenteric vein (solid arrow). Note the mesenteric varices (arrowheads). (c) Coronal oblique reformatted image displays the full extent of the lesion encasing the superior mesenteric artery. Open surgical biopsy of the mass revealed sclerosing mesenteritis.
|
|
View larger version (136K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 6b. Sclerosing mesenteritis in a 70-year-old man with recurrent rectal bleeding. (a) Axial contrast-enhanced CT image of the midabdomen shows an 8.5 x 3-cm soft-tissue mass at the root of the mesentery (solid arrows). The lesion contains coarse calcifications (open arrow). Mesenteric varices are present (arrowheads). (b) Axial contrast-enhanced CT image obtained 3 cm above a shows encasement of the superior mesenteric artery (open arrow) and near occlusion of the superior mesenteric vein (solid arrow). Note the mesenteric varices (arrowheads). (c) Coronal oblique reformatted image displays the full extent of the lesion encasing the superior mesenteric artery. Open surgical biopsy of the mass revealed sclerosing mesenteritis.
|
|
View larger version (117K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 6c. Sclerosing mesenteritis in a 70-year-old man with recurrent rectal bleeding. (a) Axial contrast-enhanced CT image of the midabdomen shows an 8.5 x 3-cm soft-tissue mass at the root of the mesentery (solid arrows). The lesion contains coarse calcifications (open arrow). Mesenteric varices are present (arrowheads). (b) Axial contrast-enhanced CT image obtained 3 cm above a shows encasement of the superior mesenteric artery (open arrow) and near occlusion of the superior mesenteric vein (solid arrow). Note the mesenteric varices (arrowheads). (c) Coronal oblique reformatted image displays the full extent of the lesion encasing the superior mesenteric artery. Open surgical biopsy of the mass revealed sclerosing mesenteritis.
|
|
Retractile mesenteritis cannot be distinguished from a carcinoid tumor or lymphoma without extensive histologic sampling, which often requires open surgical biopsy. Although the disease process is usually indolent and follows a benign course, in some cases the infiltrative nature of the fibrosis may result in serious complications, including thrombosis of the mesenteric vessels with secondary variceal bleeding (Fig 6). Scarring with retraction of the mesentery and encasement of small bowel loops can lead to ischemia or obstruction. Retractile mesenteritis has been associated with other conditions such as retroperitoneal fibrosis, lymphoma, and Gardner syndrome.
|
Secondary Mesenteric Tumors
|
|---|
Major Pathways for the Spread of Tumor to the Mesentery
Tumors originating in the abdomen or elsewhere in the body can disseminate to the mesentery in four major ways (16) (Fig 7): (a) direct spread along the mesenteric vessels and surrounding fat, (b) extension via the mesenteric lymphatics, (c) embolic hematogenous spread, and (d) intraperitoneal seeding. Although convenient, this classification is somewhat arbitrary, since many neoplasms spread by more than one route.
View larger version (108K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 7a. Dissemination of tumor through the mesentery. Drawings illustrate the four major patterns of mesenteric tumor spread: direct spread along the mesenteric vessels and surrounding fat (a), extension through the mesenteric lymphatics (b), embolic hematogenous spread (c), and intraperitoneal seeding (d).
|
|
View larger version (101K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 7b. Dissemination of tumor through the mesentery. Drawings illustrate the four major patterns of mesenteric tumor spread: direct spread along the mesenteric vessels and surrounding fat (a), extension through the mesenteric lymphatics (b), embolic hematogenous spread (c), and intraperitoneal seeding (d).
|
|
View larger version (98K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 7c. Dissemination of tumor through the mesentery. Drawings illustrate the four major patterns of mesenteric tumor spread: direct spread along the mesenteric vessels and surrounding fat (a), extension through the mesenteric lymphatics (b), embolic hematogenous spread (c), and intraperitoneal seeding (d).
|
|
View larger version (78K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 7d. Dissemination of tumor through the mesentery. Drawings illustrate the four major patterns of mesenteric tumor spread: direct spread along the mesenteric vessels and surrounding fat (a), extension through the mesenteric lymphatics (b), embolic hematogenous spread (c), and intraperitoneal seeding (d).
|
|
Direct Spread to the Mesentery
Gastrointestinal Carcinoid Tumor.—
Gastrointestinal carcinoid tumors arise from neuroendocrine cells in the intestinal mucosa or submucosa. Although these slow-growing tumors are rare (representing only 2% of tumors of the gastrointestinal tract), they are the most common malignant neoplasm of the small intestine (17). Approximately 40%–80% of gastrointestinal carcinoids spread to the mesentery, either by direct extension or through the local lymphatics (18, 19). The distal ileum is the most frequent location of the primary lesion (20). The mesenteric mass is usually discovered first, when patients present with nonspecific abdominal pain. Alternatively, patients with hepatic metastases may present with the carcinoid syndrome caused by the release of vasoactive substances such as serotonin and 5-hydroxytryptophan into the systemic circulation. These patients experience paroxysmal flushing, diarrhea, episodes of wheezing, and right-sided heart failure caused by stenoses of the tricuspid and pulmonary valves.
At CT, the most common manifestation of mesenteric carcinoid tumors is that of an enhancing soft-tissue mass with linear bands radiating in the mesenteric fat (Fig 8). Radiologic-pathologic correlation has shown that these radiating strands of soft tissue do not generally represent tumor infiltration along neurovascular bundles but rather result from the intense fibrotic proliferation and desmoplastic reaction in the mesenteric fat and the adjacent mesenteric vessels caused by the release of serotonin and other hormones from the primary tumor (18). Calcifications are visible in up to 70% of lesions at CT (Fig 9) (18). Thickening of adjacent small bowel loops caused by tumor infiltration or by ischemia owing to sclerosis of mesenteric vessels as well as angulation can be present (Fig 9) (21). The primary tumor is often small, sometimes occult, and only occasionally diagnosed at CT (Fig 10) (22). Morphologic appearances include a well-defined, hypervascular enhancing mass (Figs 9, 10) or regional intestinal wall thickening (23). Administration of water as an oral contrast agent (Fig 10) may help enhance detection of the primary focus.
View larger version (143K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 8a. Carcinoid tumor in a 57-year-old man with persistent diarrhea. (a) Axial contrast-enhanced CT image shows a 6-cm enhancing mass at the root of the mesentery (arrows). (b) Axial contrast-enhanced CT image obtained 4 cm below a shows tethering, angulation, and thickening of small bowel loops (arrows). Note beading of the mesenteric vessels (arrowhead). (c) Coronal reformatted image displays radiating strands of soft tissue extending into the mesenteric fat (arrowheads). Surgical biopsy of the mass revealed metastatic carcinoid tumor.
|
|
View larger version (149K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 8b. Carcinoid tumor in a 57-year-old man with persistent diarrhea. (a) Axial contrast-enhanced CT image shows a 6-cm enhancing mass at the root of the mesentery (arrows). (b) Axial contrast-enhanced CT image obtained 4 cm below a shows tethering, angulation, and thickening of small bowel loops (arrows). Note beading of the mesenteric vessels (arrowhead). (c) Coronal reformatted image displays radiating strands of soft tissue extending into the mesenteric fat (arrowheads). Surgical biopsy of the mass revealed metastatic carcinoid tumor.
|
|
View larger version (130K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 8c. Carcinoid tumor in a 57-year-old man with persistent diarrhea. (a) Axial contrast-enhanced CT image shows a 6-cm enhancing mass at the root of the mesentery (arrows). (b) Axial contrast-enhanced CT image obtained 4 cm below a shows tethering, angulation, and thickening of small bowel loops (arrows). Note beading of the mesenteric vessels (arrowhead). (c) Coronal reformatted image displays radiating strands of soft tissue extending into the mesenteric fat (arrowheads). Surgical biopsy of the mass revealed metastatic carcinoid tumor.
|
|
View larger version (125K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 9a. Carcinoid tumor in a 60-year-old man with abdominal pain and distention. (a) Axial contrast-enhanced CT image shows a small ill-defined mass with a coarse calcification in the mesentery (arrow). Note the dilated fluid-filled small bowel loops (arrowheads). (b) Axial contrast-enhanced CT image obtained 35 mm above a demonstrates a smooth enhancing mass in the ileum (arrow) that proved to be the primary tumor. The ileal mass was not diagnosed prospectively. (c) Contrast-enhanced CT image obtained 2 months later, when the patient returned with recurrent pain, demonstrates that the partial small bowel obstruction has resolved but shows focal thickening of a small bowel loop (arrowheads), indicating probable ischemia. The primary tumor is unchanged (arrow). Findings from surgical exploration confirmed the diagnosis of ileal carcinoid metastatic to the mesentery.
|
|
View larger version (133K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 9b. Carcinoid tumor in a 60-year-old man with abdominal pain and distention. (a) Axial contrast-enhanced CT image shows a small ill-defined mass with a coarse calcification in the mesentery (arrow). Note the dilated fluid-filled small bowel loops (arrowheads). (b) Axial contrast-enhanced CT image obtained 35 mm above a demonstrates a smooth enhancing mass in the ileum (arrow) that proved to be the primary tumor. The ileal mass was not diagnosed prospectively. (c) Contrast-enhanced CT image obtained 2 months later, when the patient returned with recurrent pain, demonstrates that the partial small bowel obstruction has resolved but shows focal thickening of a small bowel loop (arrowheads), indicating probable ischemia. The primary tumor is unchanged (arrow). Findings from surgical exploration confirmed the diagnosis of ileal carcinoid metastatic to the mesentery.
|
|
View larger version (133K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 9c. Carcinoid tumor in a 60-year-old man with abdominal pain and distention. (a) Axial contrast-enhanced CT image shows a small ill-defined mass with a coarse calcification in the mesentery (arrow). Note the dilated fluid-filled small bowel loops (arrowheads). (b) Axial contrast-enhanced CT image obtained 35 mm above a demonstrates a smooth enhancing mass in the ileum (arrow) that proved to be the primary tumor. The ileal mass was not diagnosed prospectively. (c) Contrast-enhanced CT image obtained 2 months later, when the patient returned with recurrent pain, demonstrates that the partial small bowel obstruction has resolved but shows focal thickening of a small bowel loop (arrowheads), indicating probable ischemia. The primary tumor is unchanged (arrow). Findings from surgical exploration confirmed the diagnosis of ileal carcinoid metastatic to the mesentery.
|
|
View larger version (139K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 10a. Carcinoid tumor in a 65-year-old man with an incidentally found mesenteric mass. (a) Axial CT image obtained in the arterial phase of enhancement shows a 4-cm enhancing mass at the root of the mesentery (arrow). There is a 1.5-cm enhancing mass in the wall of the proximal small intestine near the ligament of Treitz (arrowhead). (b) Coronal reformatted image shows that the mesenteric mass is contiguous with the primary tumor. At pathologic analysis, a jejunal carcinoid tumor was found to be extending through the intestinal wall to invade an adjacent lymph node.
|
|
View larger version (112K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 10b. Carcinoid tumor in a 65-year-old man with an incidentally found mesenteric mass. (a) Axial CT image obtained in the arterial phase of enhancement shows a 4-cm enhancing mass at the root of the mesentery (arrow). There is a 1.5-cm enhancing mass in the wall of the proximal small intestine near the ligament of Treitz (arrowhead). (b) Coronal reformatted image shows that the mesenteric mass is contiguous with the primary tumor. At pathologic analysis, a jejunal carcinoid tumor was found to be extending through the intestinal wall to invade an adjacent lymph node.
|
|
Other Neoplasms.—
Several intraabdominal malignancies, including gastric, pancreatic, biliary, and colon cancer, may extend directly into the leaves of the mesentery or spread along the mesenteric vessels (24). About 40% of patients with newly diagnosed adenocarcinoma of the pancreas have unresectable, locally advanced disease with tumor extension along the root of the mesentery and encasement of the major mesenteric vessels (Fig 11) (25).
View larger version (123K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 11a. Adenocarcinoma of the pancreas in a 57-year-old woman with abdominal pain. (a) Axial CT image obtained in the arterial phase of enhancement shows a subtle soft-tissue mass abutting the superior mesenteric artery (arrow). The mass has lower attenuation than that of normal pancreatic parenchyma. (b) Coronal reformatted image from the arterial phase of enhancement allows better appreciation of the tumor growing along the superior mesenteric artery and encasing the vessel (arrow). (c) Coronal reformatted image from the venous phase of enhancement shows marked narrowing of the superior mesenteric vein (arrow). Coronal reformatted images allow a more confident diagnosis of unresectability. The diagnosis of adenocarcinoma of the pancreas was confirmed by means of percutaneous biopsy.
|
|
View larger version (112K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 11b. Adenocarcinoma of the pancreas in a 57-year-old woman with abdominal pain. (a) Axial CT image obtained in the arterial phase of enhancement shows a subtle soft-tissue mass abutting the superior mesenteric artery (arrow). The mass has lower attenuation than that of normal pancreatic parenchyma. (b) Coronal reformatted image from the arterial phase of enhancement allows better appreciation of the tumor growing along the superior mesenteric artery and encasing the vessel (arrow). (c) Coronal reformatted image from the venous phase of enhancement shows marked narrowing of the superior mesenteric vein (arrow). Coronal reformatted images allow a more confident diagnosis of unresectability. The diagnosis of adenocarcinoma of the pancreas was confirmed by means of percutaneous biopsy.
|
|
View larger version (118K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 11c. Adenocarcinoma of the pancreas in a 57-year-old woman with abdominal pain. (a) Axial CT image obtained in the arterial phase of enhancement shows a subtle soft-tissue mass abutting the superior mesenteric artery (arrow). The mass has lower attenuation than that of normal pancreatic parenchyma. (b) Coronal reformatted image from the arterial phase of enhancement allows better appreciation of the tumor growing along the superior mesenteric artery and encasing the vessel (arrow). (c) Coronal reformatted image from the venous phase of enhancement shows marked narrowing of the superior mesenteric vein (arrow). Coronal reformatted images allow a more confident diagnosis of unresectability. The diagnosis of adenocarcinoma of the pancreas was confirmed by means of percutaneous biopsy.
|
|
Extension via the Mesenteric Lymphatics
Lymphoma.—
Lymphoma is the most common malignant neoplasm affecting the mesentery (3). Approximately 30%–50% of patients with non-Hodgkin lymphoma harbor disease in the mesenteric lymph nodes. Markedly mesenteric adenopathy can also be present in chronic lymphocytic leukemia. Patterns of mesenteric lymphoma at CT include multiple, rounded, mildly enhancing, homogeneous masses that often encase the mesenteric vessels (Fig 12) and produce the "sandwich sign" (26); a large, lobulated, "cakelike," heterogeneous mass with low-attenuation areas of necrosis displacing small bowel loops (Fig 13); or an ill-defined infiltration of the mesenteric fat, particularly after successful chemotherapy (Fig 14) (3,13). Bulky retroperitoneal adenopathy commonly accompanies the mesenteric disease and should be a clue to the diagnosis (Fig 12) (2).
View larger version (114K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 12a. Follicular mixed lymphoma in a 68-year-old woman. (a) Axial contrast-enhanced CT image of the lower abdomen shows a 5.5-cm soft-tissue mass in the mesentery (arrow). (b) Axial contrast-enhanced CT image obtained at the level of the superior mesenteric artery demonstrates an ill-defined, infiltrating retroperitoneal mass (arrows) encasing the superior mesenteric artery, aorta, inferior vena cava, and right renal artery.
|
|
View larger version (126K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 12b. Follicular mixed lymphoma in a 68-year-old woman. (a) Axial contrast-enhanced CT image of the lower abdomen shows a 5.5-cm soft-tissue mass in the mesentery (arrow). (b) Axial contrast-enhanced CT image obtained at the level of the superior mesenteric artery demonstrates an ill-defined, infiltrating retroperitoneal mass (arrows) encasing the superior mesenteric artery, aorta, inferior vena cava, and right renal artery.
|
|
View larger version (132K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 13a. Mesenteric lymphoma in a 77-year-old man who presented with a palpable abdominal mass. (a) Axial contrast-enhanced CT image of the lower abdomen shows a large soft-tissue mass in the mesentery (arrows) that displaces the small intestine. The mass has low attenuation, indicating extensive necrosis. (b) Axial contrast-enhanced CT image of the midabdomen shows the mass is encasing the superior mesenteric vein (arrowhead). Large retroperitoneal nodes are also present (open arrow). Percutaneous biopsy of the mass yielded B-cell lymphoma.
|
|
View larger version (136K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 13b. Mesenteric lymphoma in a 77-year-old man who presented with a palpable abdominal mass. (a) Axial contrast-enhanced CT image of the lower abdomen shows a large soft-tissue mass in the mesentery (arrows) that displaces the small intestine. The mass has low attenuation, indicating extensive necrosis. (b) Axial contrast-enhanced CT image of the midabdomen shows the mass is encasing the superior mesenteric vein (arrowhead). Large retroperitoneal nodes are also present (open arrow). Percutaneous biopsy of the mass yielded B-cell lymphoma.
|
|
View larger version (168K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 14. Non-Hodgkin lymphoma in clinical remission in a 56-year-old man after chemotherapy. Axial contrast-enhanced CT image of the midabdomen shows insignificant adenopathy except for a small left paraaortic node, consistent with remission. Note the very subtle increase in the attenuation of the mesenteric fat (arrow) surrounding the mesenteric vessels. Pretreatment CT images (not shown) had shown extensive mesenteric lymphadenopathy.
|
|
Other Malignancies.—
Metastases from colon cancer, ovarian carcinoma, breast cancer, lung cancer, carcinoid, and melanoma can spread to mesenteric lymph nodes. However, the degree of nodal enlargement seen in mesenteric metastatic disease is less pronounced than that seen in mesenteric lymphoma, and the distribution of involved nodes is comparatively more localized in metastatic disease (Fig 15) (3).
View larger version (116K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 15. Recurrent disease in a 56-year-old man with a history of lung cancer and lymphoma. Axial contrast-enhanced CT image of the midabdomen shows bulky mesenteric adenopathy surrounding the mesenteric vessels (arrows). There is thickening of the wall of the descending colon (arrowheads). Although this appearance is very suggestive of lymphoma, percutaneous biopsy of the mesenteric nodes revealed metastatic lung cancer.
|
|
Differential Diagnosis.—
Several infectious and inflammatory conditions, such as atypical mycobacterial infection and tuberculosis, other inflammatory conditions, and vascular abnormalities, produce mesenteric nodal enlargement that mimics lymphoma or metastatic disease. However, in the majority of cases, inflammatory adenopathy remains discrete, whereas lymphomatous nodes tend to coalesce, a helpful distinguishing feature.
The rising prevalence of abdominal atypical mycobacterial infection and the reemergence of tuberculosis can be attributed to the increasing number of immunocompromised hosts, particularly patients infected with human immunodeficiency virus (HIV), those who undergo chronic steroid therapy, and intravenous drug users. Abdominal tuberculosis is transmitted by three major routes: (a) ingestion of infected milk or sputum, which carries the infection through the intestine to local lymph nodes; (b) hematogenous spread from the lungs to abdominal and paraaortic lymph nodes; and (c) direct spread from the serosal surface of infected organs such as the fallopian tubes. Intraabdominal lymphadenopathy is the most common manifestation of abdominal tuberculosis and infection with Mycobacterium avium–intracellulare complex. Affected nodes often demonstrate rim enhancement in the peripheral inflammatory reaction and a low-attenuation center in the central caseous necrosis (Fig 16) or a multilocular appearance (27,28).
View larger version (143K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 16. M avium-intracellulare infection in a 37-year-old man infected with HIV (human immunodeficiency virus). Axial contrast-enhanced CT image of the midabdomen shows multiple enlarged nodes (arrows) surrounding the mesenteric vessels. Some of the nodes contain low-attenuation areas and demonstrate rim enhancement (arrowhead). M avium-intracellulare was cultured from the patient’s stool.
|
|
Whipple disease, a very rare condition predominantly affecting young white men and caused by the Gram-positive bacillus Trophermyma whipplei, should be included in the differential diagnosis of low-attenuation nodes in the mesentery (Fig 17).
View larger version (121K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 17. Known Whipple disease in a 43-year-old woman. Axial contrast-enhanced CT image of the lower abdomen shows a conglomerate of low-attenuation nodes with rim enhancement in the mesentery (arrow).
|
|
Enlarged mesenteric nodes can also be seen in some noninfectious inflammatory conditions, such as celiac sprue, Crohn disease, systemic mastocytosis, and sarcoidosis (29,30). Rare cases of mesenteric Castleman disease manifesting as intensely enhancing mesenteric adenopathy have been reported (31).
Patients with portal hypertension or portal or mesenteric vein thrombosis may develop portosystemic collateral varices in the mesentery. Care should be taken to avoid confusing them with adenopathy on unenhanced CT images (Fig 18).
View larger version (149K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 18a. Mesenteric varices in a 55-year-old man with hepatocellular carcinoma and portal vein thrombosis. (a) Axial CT image of the midabdomen obtained in the arterial phase of enhancement shows multiple round soft masses in the mesentery (arrow). (b) On an axial CT image obtained in the venous phase of enhancement, these "masses" (arrow) are enhancing to the same degree as the superior mesenteric vein and are shown to represent mesenteric varices.
|
|
View larger version (152K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 18b. Mesenteric varices in a 55-year-old man with hepatocellular carcinoma and portal vein thrombosis. (a) Axial CT image of the midabdomen obtained in the arterial phase of enhancement shows multiple round soft masses in the mesentery (arrow). (b) On an axial CT image obtained in the venous phase of enhancement, these "masses" (arrow) are enhancing to the same degree as the superior mesenteric vein and are shown to represent mesenteric varices.
|
|
Embolic Hematogenous Spread
Embolic metastases from melanoma, breast cancer, and lung cancer can reach the antimesenteric border of the small intestine through small mesenteric arterial branches. These tumor deposits can act as a lead point for intussusception. The small intestine and its mesentery are the most common site of gastrointestinal metastases from melanoma (32). In a series of 230 patients with melanoma reviewed by Kawashima et al (33), 7.4% had evidence of small bowel involvement at CT. Metastases from melanoma classically manifest as enhancing mural nodules protruding into the intestinal lumen or as focal thickening of the intestinal wall (Fig 19). Metastases are even more commonly described in autopsy series, as they have been found in up to 35%–58% of cases (33).
View larger version (131K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 19. Metastatic melanoma in a 50-year-old man presenting with vomiting. Axial contrast-enhanced CT image of the lower abdomen shows several enhancing masses in the small bowel mesentery (solid arrows) due to metastatic melanoma. An ileoileal intussusception is present in the right lower quadrant (open arrow) and is causing partial small bowel obstruction. Melanoma implants are also seen in dilated loops of small intestine (arrowheads).
|
|
Intraperitoneal Seeding
Because of the natural flow of fluid in the peritoneal cavity, the portion of mesentery close to the terminal ileum in the right lower quadrant is a common site of intraperitoneal tumor seeding. Tumor deposits within the leaves of the mesentery can appear as focal masses (Figs 20, 21) or can produce a diffuse infiltration of the mesenteric fat, the so-called stellate appearance of the mesentery.
View larger version (118K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 20a. Malignant gastrointestinal stromal tumor in a 30-year-old man. (a) Axial contrast-enhanced CT image of the lower abdomen shows two small low-attenuation mesenteric masses adjacent to nondilated loops of small intestine (arrows). (b) Axial contrast-enhanced CT image obtained 4 cm cephalad shows a large heterogeneous low-attenuation omental mass (arrow). Metastases from gastrointestinal stromal tumor are typically low attenuation.
|
|
View larger version (122K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 20b. Malignant gastrointestinal stromal tumor in a 30-year-old man. (a) Axial contrast-enhanced CT image of the lower abdomen shows two small low-attenuation mesenteric masses adjacent to nondilated loops of small intestine (arrows). (b) Axial contrast-enhanced CT image obtained 4 cm cephalad shows a large heterogeneous low-attenuation omental mass (arrow). Metastases from gastrointestinal stromal tumor are typically low attenuation.
|
|
View larger version (121K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 21a. Metastatic ovarian carcinoma in a 73-year-old woman with a pelvic mass. (a) Axial contrast-enhanced CT image of the lower abdomen shows several calcified masses in the mesentery and omentum (arrows). (b) Coronal reformatted image depicts the extent of the intraperitoneal spread of this ovarian cancer. The primary tumor appears as a large calcified pelvic mass (arrows). Surgical resection revealed a high-grade serous carcinoma of the ovary with extensive psammoma bodies.
|
|
View larger version (123K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 21b. Metastatic ovarian carcinoma in a 73-year-old woman with a pelvic mass. (a) Axial contrast-enhanced CT image of the lower abdomen shows several calcified masses in the mesentery and omentum (arrows). (b) Coronal reformatted image depicts the extent of the intraperitoneal spread of this ovarian cancer. The primary tumor appears as a large calcified pelvic mass (arrows). Surgical resection revealed a high-grade serous carcinoma of the ovary with extensive psammoma bodies.
|
|
Carcinomatosis.—
The stellate appearance of the mesentery is more commonly seen in association with peritoneal carcinomatosis, particularly if caused by breast, gastric, pancreatic, or ovarian cancer (Fig 22) (30). Lobular breast carcinoma metastasizes to the mesentery and gastrointestinal tract more frequently than infiltrating ductal carcinoma (34).
View larger version (137K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 22. Metastatic breast cancer in a 57-year-old woman with a palpable abdominal mass and a history of breast cancer. Axial contrast-enhanced CT image of the midabdomen shows an ill-defined soft-tissue mass infiltrating the root of the mesentery and encasing the mesenteric vessels (arrows). Surgical biopsy revealed metastatic lobular breast carcinoma.
|
|
Peritoneal lymphomatosis (Fig 23) results from peritoneal seeding of primary gastrointestinal lymphomas and cannot be distinguished from carcinomatosis on the basis of CT appearance (35).
View larger version (123K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 23. Peritoneal lymphomatosis in a 40-year-old man with a right lower quadrant mass. Axial contrast-enhanced CT image of the midabdomen shows extensive and diffuse soft-tissue infiltration of the mesenteric fat (arrows). Omental caking is also present (arrowheads). Percutaneous biopsy of the omental mass yielded high-grade lymphoma similar to Burkitt lymphoma.
|
|
Malignant Peritoneal Mesothelioma.—
Malignant peritoneal mesothelioma is a rare, usually lethal neoplasm arising from the mesothelial cells lining the serosal surface of the peritoneal cavity. The majority of patients have a history of asbestos exposure (36). CT manifestations include ascites in variable amounts, enhancement of the peritoneum after intravenous administration of contrast material, focal peritoneal soft-tissue masses, and infiltration of the omentum (Fig 24). Spread to the mesentery is common and appears as increased attenuation in the mesenteric fat, perivascular soft-tissue thickening, and rigidity of the vascular bundles (36). This so-called stellate appearance is caused by microscopic infiltration of tumor within the fat along the mesenteric blood vessels (37). Associated pleural calcifications, thickening, or effusions are common.
View larger version (145K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 24. Peritoneal mesothelioma in a 35-year-old man with abdominal distention. Axial contrast-enhanced CT image of the midabdomen shows ascites and peritoneal implants of tumor (arrowheads). Linear bands of soft-tissue attenuation run through the mesenteric fat, indicating tumor infiltration (arrow). Percutaneous biopsy of a focal peritoneal mass revealed malignant mesothelioma.
|
|
Differential Diagnosis.—
Involvement of the peritoneum and mesentery with tuberculosis generally occurs secondary to infection in the gastrointestinal tract. Differentiating tuberculous peritonitis from carcinomatosis at CT can be quite challenging. In addition to diffuse thickening and fine nodularity of the mesentery and infiltration of the mesenteric fat, CT features that suggest the diagnosis of tuberculous peritonitis include enhancement and smooth thickening of the peritoneum, high-attenuation ascites, thickening of the intestinal wall (particularly the terminal ileum and cecum), and low-attenuation mesenteric nodes (Fig 25) (13,27,38).
View larger version (146K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 25a. Peritoneal tuberculosis in a 45-year-old woman with abdominal distention. (a) Axial contrast-enhanced CT image of the lower abdomen shows a moderate amount of ascites. There is enhancement of the peritoneal lining (arrowhead) and nodularity in the mesenteric fat (arrow). (b) Axial contrast-enhanced CT image of the pelvis shows ascites without a discrete ovarian mass. The patient underwent exploratory laparotomy for presumed ovarian cancer. Histologic findings from peritoneal biopsies yielded caseating granulomas consistent for peritoneal tuberculosis.
|
|
View larger version (124K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 25b. Peritoneal tuberculosis in a 45-year-old woman with abdominal distention. (a) Axial contrast-enhanced CT image of the lower abdomen shows a moderate amount of ascites. There is enhancement of the peritoneal lining (arrowhead) and nodularity in the mesenteric fat (arrow). (b) Axial contrast-enhanced CT image of the pelvis shows ascites without a discrete ovarian mass. The patient underwent exploratory laparotomy for presumed ovarian cancer. Histologic findings from peritoneal biopsies yielded caseating granulomas consistent for peritoneal tuberculosis.
|
|
|
Conclusion
|
|---|
CT remains the dominant imaging modality for the diagnosis of mesenteric neoplasms. The Table presents a systematic approach to the differential diagnosis of mesenteric lesions detected at CT.
|
References
|
|---|
- Yaunopoulos K, Stout AP. Primary solid tumors of the mesentery. Cancer 1963; 16:914-927.[CrossRef][Medline]
- Bernardino ME, Jing BS, Wallace S. Computed tomography diagnosis of mesenteric masses. AJR Am J Roentgenol 1979; 132:33-36.[Abstract]
- Whitley NO, Bohlman ME, Baker LP. CT patterns of mesenteric disease. J Comput Assist Tomogr 1982; 6:490-496.[Medline]
- Casillas J, Sais GJ, Greve JL, Iparraguirre MC, Morillo G. Imaging of intra- and extraabdominal desmoid tumors. RadioGraphics 1991; 11:959-968.[Abstract]
- Kawashima A. Goldman SM, Fishman EK, et al. CT of intraabdominal desmoid tumors: is the tumor different in patients with Gardner’s disease? AJR Am J Roentgenol 1994; 162:339-342.
- Jones IT, Jagelman DG, Fazio VW, Lavery IC, Weakley FL, McGannon E. Desmoid tumors in familial polyposis coli. Ann Surg 1986; 204:94-97.[Medline]
- Brooks AP, Reznek RH, Nugent K, Farmer KC, Thomson JP, Phillips RK. CT appearances of desmoid tumours in familial adenomatous polyposis: further observations. Clin Radiol 1994; 49:601-607.[CrossRef][Medline]
- Einstein DM, Tagliabue JR, Desai RK. Abdominal desmoids: CT findings in 25 patients. AJR Am J Roentgenol 1991; 157:275-279.[Abstract/Free Full Text]
- Ramboer K, Moons P, De Breuck Y, Van Hoe L, Baert AL. Benign mesenteric schwannoma: MRI findings. J Belge Radiol 1998; 81:3-4.[Medline]
- Sato M, Ishida H, Konno K, et al. Mesenteric lipoma: report of a case with emphasis on US findings. Eur Radiol 2002; 12:793-795.[CrossRef][Medline]
- Miettinen M, Monihan JM, Sarlomo-Raikala M, et al. Gastrointestinal stromal tumors/smooth muscle tumors (GISTs) primary in the omentum and mesentery: clinicopathologic and immunohistochemical study of 26 cases. Am J Surg Pathol 1999; 23:1109-1118.[CrossRef][Medline]
- Mizoe A, Takebe K, Kanematsu T. Primary leiomyosarcoma of the jejunal mesentery: report of a case. Surg Today 1998; 28:87-90.[CrossRef][Medline]
- Mindelzun RE, Jeffrey RB, Jr, Lane MJ, Silverman PM. The misty mesentery on CT: differential diagnosis. AJR Am J Roentgenol 1996; 167:61-65.[Free Full Text]
- Sabate JM, Torrubia S, Maideu J, Franquet T, Monill JM, Perez C. Sclerosing mesenteritis: imaging findings in 17 patients. AJR Am J Roentgenol 1999; 172:625-629.[Abstract/Free Full Text]
- Phillips RH, Carr RA, Preston R, et al. Sclerosing mesenteritis involving the pancreas: two cases of a rare cause of abdominal mass mimicking malignancy. Eur J Gastroenterol Hepatol 1999; 11:1323-1329.[Medline]
- Meyers MA, Oliphant M, Berne AS, Feldberg MA. The peritoneal ligaments and mesenteries: pathways of intraabdominal spread of disease. Radiology 1987; 163:593-604.[Abstract/Free Full Text]
- Wallace S, Ajani JA, Charnsangavej C, et al. Carcinoid tumors: imaging procedures and interventional radiology. World J Surg 1996; 20:147-156.[CrossRef][Medline]
- Pantongrag-Brown L, Buetow PC, Carr NJ, Lichtenstein JE, Buck JL. Calcification and fibrosis in mesenteric carcinoid tumor: CT findings and pathologic correlation. AJR Am J Roentgenol 1995; 164:387-391.[Abstract/Free Full Text]
- Burke AP, Thomas RM, Elsayed AM, Sobin LH. Carcinoids of the jejunum and ileum: an immunohistochemical and clinicopathologic study of 167 cases. Cancer 1997; 79:1086-1093.[CrossRef][Medline]
- Godwin JD, 2nd. Carcinoid tumors: an analysis of 2,837 cases. Cancer 1975; 36:560-569.[CrossRef][Medline]
- Buck JL, Sobin LH. Carcinoids of the gastrointestinal tract. RadioGraphics 1990; 10:1081-1095.[Abstract]
- Woodard PK, Feldman JM, Paine SS, Baker ME. Midgut carcinoid tumors: CT findings and biochemical profiles. J Comput Assist Tomogr 1995; 19:400-405.[Medline]
- Sugimoto E, Lorelius LE, Eriksson B, Oberg K. Midgut carcinoid tumours: CT appearance. Acta Radiol 1995; 36:367-371.[Medline]
- Silverman PM, Baker ME, Cooper C, Kelvin FM. Computed tomography of mesenteric disease. RadioGraphics 1987; 7:309-320.[Abstract]
- McMahon PM, Halpern EF, Fernandez-del Castillo C, Clark JW, Gazelle GS. Pancreatic cancer: cost-effectiveness of imaging technologies for assessing resectability. Radiology 2001; 221:93-106.[Abstract/Free Full Text]
- Mueller PR, Ferrucci JT, Jr, Harbin WP, Kirkpatrick RH, Simeone JF, Wittenberg J. Appear-ance of lymphomatous involvement of the mesentery by ultrasonography and body computed tomography: the "sandwich sign". Radiology 1980; 134:467-473.[Abstract/Free Full Text]
- Jadvar H, Mindelzun RE, Olcott EW, Levitt DB. Still the great mimicker: abdominal tuberculosis. AJR Am J Roentgenol 1997; 168:1455-1460.[Abstract/Free Full Text]
- Pantongrag-Brown L, Krebs TL, Daly BD, et al. Frequency of abdominal CT findings in AIDS patients with M avium complex bacteraemia. Clin Radiol 1998; 53:816-819.[CrossRef][Medline]
- Avila NA, Ling A, Worobec AS, Mican JM, Metcalfe DD. Systemic mastocytosis: CT and US features of abdominal manifestations. Radiology 1997; 202:367-372.[Abstract/Free Full Text]
- Healy JC, Reznek RH. The peritoneum, mesenteries and omenta: normal anatomy and pathological processes. Eur Radiol 1998; 8:886-900.[CrossRef][Medline]
- Demirpolat G, Pourbagher A, Hekimgil M, et al. Mesenteric Castleman’s disease: case report. Abdom Imaging 2000; 25:551-553.[CrossRef][Medline]
- McDermott VG, Low VH, Keogan MT, Lawrence JA, Paulson EK. Malignant melanoma metastatic to the gastrointestinal tract. AJR Am J Roentgenol 1996; 166:809-813.[Abstract/Free Full Text]
- Kawashima A, Fishman EK, Kuhlman JE, Schuchter LM. CT of malignant melanoma: patterns of small bowel and mesenteric involvement. J Comput Assist Tomogr 1991; 15:570-574.[Medline]
- Winston CB, Hadar O, Teitcher JB, et al. Metastatic lobular carcinoma of the breast: patterns of spread in the chest, abdomen, and pelvis on CT. AJR Am J Roentgenol 2000; 175:795-800.[Abstract/Free Full Text]
- Kim Y, Cho O, Song S, Lee H, Rhim H, Koh B. Peritoneal lymphomatosis: CT findings. Abdom Imaging 1998; 23:87-90.[CrossRef][Medline]
- Guest PJ, Reznek RH, Selleslag D, Geraghty R, Slevin M. Peritoneal mesothelioma: the role of computed tomography in diagnosis and follow up. Clin Radiol 1992; 45:79-84.[CrossRef][Medline]
- Smith TR. Malignant peritoneal mesothelioma: marked variability of CT findings. Abdom Imaging 1994; 19:27-29.[CrossRef][Medline]
- Ha HK, Jung JI, Lee MS, et al. CT differentiation of tuberculous peritonitis and peritoneal carcinomatosis. AJR Am J Roentgenol 1996; 167:743-748.[Abstract/Free Full Text]
This article has been cited by other articles:
|
|
|
|
 
P. T. Johnson, K. M. Horton, and E. K. Fishman
Nonvascular Mesenteric Disease: Utility of Multidetector CT with 3D Volume Rendering
RadioGraphics,
May 1, 2009;
29(3):
721 - 740.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
Y. J. Jeong, S. Kim, S. W. Kwak, N. K. Lee, J. W. Lee, K.-I. Kim, K. U. Choi, and T. Y. Jeon
Neoplastic and Nonneoplastic Conditions of Serosal Membrane Origin: CT Findings
RadioGraphics,
May 1, 2008;
28(3):
801 - 818.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
R. H. Donkol, S. Monib, and I. Eltounsi
Occult Testicular Teratoma Presenting With Solid Mesenteric Metastasis
J. Ultrasound Med.,
May 1, 2007;
26(5):
675 - 678.
[Full Text]
[PDF]
|
|
|
|
|
|
|
M Brookes, D MacVicar, and J Husband
Metastatic carcinoma of the breast: the appearances of metastatic spread to the abdomen and pelvis as demonstrated by CT
Br. J. Radiol.,
April 1, 2007;
80(952):
284 - 292.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. F. Scarsbrook, A. Ganeshan, J. Statham, R. V. Thakker, A. Weaver, D. Talbot, P. Boardman, K. M. Bradley, F. V. Gleeson, and R. R. Phillips
Anatomic and Functional Imaging of Metastatic Carcinoid Tumors
RadioGraphics,
March 1, 2007;
27(2):
455 - 477.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
P. Yenarkarn, R. F. Thoeni, and D. Hanks
Case 107: Lymphoma of the Mesentery
Radiology,
February 1, 2007;
242(2):
628 - 631.
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. van Breda Vriesman and U. Rudloff
Regarding the Spoke Wheel Sign
Radiology,
December 1, 2006;
241(3):
947 - 948.
[Full Text]
[PDF]
|
|
|
Top
Abstract
LEARNING OBJECTIVES FOR TEST...
