carcinomatose 4

8/6/2019 Carcinomatose 4

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* From th e D epar tm en t o f R adio log y , Th e New Y ork Ho sp ital and M em orial H ospita l for C an cer and A llied D isease s, C ornellU n ive rs ity M ed ic a l C en ter , N ew Yo rk , N ew Yo rk .

SEPTEM BER , 197 3

19 8

D ISTR IBUT ION OF IN TRA -ABDOM INAL M AL IGNANTSEED ING : D EPENDENCY O N DYNAM ICS O F

FLOW OF ASC IT1C FLU ID *B y M O RTON A . M EY ERS , M .D .

NEW YORK . N EW YO RK

T HE sp read of n eo p la sm s w ith in thepen ito neal cav ity o ccu rs b y d irec t in -

vasion , true em bo lic m e tasta se s, lym pha ticex tens ion , and in trapen i ton ea l D irect inv asio n o ccu rs from lo ca lly ag gres -s iv e con tigu ous prim ary tum ors o r fromnoncont i guous le sion s alo ng m esen ten icp lanes. H em a to geneous m eta sta se s m ay fo l-low d isc re te v ascu la r rou te s, bo th v en ou san d arte ria l. S im ila r ly , lym ph atic ex tens ionan d pe rm ea tion fo llow know n an atom icchannels .

The re is, h ow ev er, on ly v ery lim ited un -de rstan d ing o f th e fac to rs con tribu ting toth e d is tribu tion o f in tra -abd om in al seed edmetas tases . It has b een gene rally a ssum edth at transcoe lom ic sp read is random or, atlea st, a fun ctio n o f serosa l im p lan ta tion inth e imm ed iate a rea o f a p rim ary neop lasm.The re la tio nsh ip o f the c ircu la tio n o f th ein duced asc itic flu id to tile t ransport ingan d depo sition of m alig nan t cells in thepen itonea l cav ity h as no t b een prev iou slyshow n . In an ea rlie r repo rt, tile obse rva -tions on sp read of in trapen iton ea l e ffus io nsd e rived from a lim ited se r ie s o f p en itone -og raph y w ere firs t reco rded .9 Em ph asis w asp laced on th e pa thw ays o f flow in the up-pe r ab dom ina l recesse s an d the ir co rre la -tio n w ith the loca lizatio n o f in trapen ito nealab scesse s rem o te from the ir sou rce. F u r-th en dynam ic observa tion s have de ta iledth e p rec ise flow p attern s d om in ating in th elow er abdom en and p elv is .

The purp ose o f th is rep o rt is to do cu -men t : ( by detai led in vivo f luonoscopican d roen tgeno log ic ob se rva tion s tha t a sc it-ic flu id is no t in a static sta te , bu t pu rsuesa con tin ua l d ynam ic flow in th e low er ab - .dom en and pe lv is a lon g d istinc t pa thw ays.

These pa thw ays a re d ete rm ined by pen -to nea l re flec tions an d reces ses , a s w e ll a sthe fo rces o f g rav ity and nega tive sub -d iap hragm a tic p re ssu re ; an d (2) th at thesite s o f lodgm en t and g row th o f in tra-p en itonea l s eeded m e ta sta ses , show n in anana lysis o f a la rge prov ed series , fo llowthe sp read of th e asc itic flu id .

MATERIAL AND METHOD

The dyn am ic p athw ay s o f flow o f in -t raper i tonea l fluid in v ivo we r e s tud ied in3 5 hosp italized pa tien ts b y the tech n iqu eof pen ito neography . T he p atien ts rang edin age from 28 to 74 yea rs , an d w ere co rn -pn ised of 22 m ales and 13 fem ales. Nonehad prev iou s abd om in al ope ratio ns. Th ep atien t is po sitioned su p ine on th e ro en t-g en ograph ic tab le. A fte r loca l anesthesia ,transabd om in a l need le pu nc tu re using aR och este r need le* is accom plish ed in thele ft sup naum b ilica l a rea . B rie f ly , the tech -n ique con sists o f the in trapen iton ea l in -jectio n o f 1 ,200-1 ,500 m l. o f n itrou s ox id efo llow ed by i o to 20 0 m l. o f 6o pe r cen tm eg lum ine d iatn izo a tet d ilu ted w ith o to7 5 m l. o f n o rm a l sa line . Th e p re sence o fin trap en itonea l gas en hances the p ositiveco n trast and he lps its n atu ra l d isp ersion .Im age am plified flu o ro sco p ic ob serv ationsde ta iled th e pa tte rns o f flow of the in tra-pen i tonea l flu id and th ese w ere co nfirm edby roen tgeno gram s o f the abdom en . Insev eral pa tien ts , th e p athw ays o f flowfo llow in g su ccessiv e o m l. inc rem en ts o fthe con tra st so lu tion w ere fluo ro sco p ica llyo bse rv ed . R ou tin e f ilm ing con sisted o f a

B Je lco In traveno us P lacem en t U nit, Je lco L abora tories ,R aritan , N . J.

t Ren ogra fin -6o , E . R . Squ ibb & Son s , N ew Yo rk .


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VOL . 119 , No . I In tra-A bdom ina l M a lignan t S eed ing 99

se ries o f io p ro jec tio ns : fro n ta l an d bo tho b liq ue s in th e p ron e T ren de lenb urg (20-3Q0 ) th en po stero an ten io r, an tero po sten io r,an d righ t an d le ft la tera l w ith the tab leh o rizo n ta l; an d th en fro n ta l and b o thob liq ue s in the su p in e T ren de lenbu rg (20-3Q0)#{149} In th e ea rly s tage s o f the inv es tiga -tio n , d ecub itu s an d cro ss-tab le la te ra l v iew sw e re also ob ta ined and con tribu ted to anu nd ers tand ing o f th e pa thw ays o f flow .Fo llow in g th e p roced u re , th e p lu gg edp la s tic cann u la left in s itu was opened tope rm it a s m uch of the ga s as po ss ib le toescap e. B o th th e w a ter-so lub le con tras tm ed ium and any res id ua l g as a re sp on -taneou s ly ab so rbed b y the p en ito neal su r-fa ce s o ve r th e n ex t few hours . S ince ren o -g rafin 6o is hy pe rto n ic , ev en the rela tiv elysm all am oun t u sed trans ien tly ind ucessom e asc itic flu id . T h is w as show n byp rog ress iv e d ilu tion o fthe con tra st m ed iumth rou ghou t the stud y .

A se ries o f 3 ca se s o f in trapen ito nea lm align an t seed ing , p ro ved a t o pe rat ion o rau topsy , from The N ew Y o rk H osp ita l andM em o ria l H osp ita l fo r C an cer and A lliedD isease s , w as rev iew ed . T he roen tgeno log ican d p atho log ic fe atu re s w ere ca refu llyan a lyzed , pa rticu la rly in term s of the pn i-m ary source an d the d istr ibu tion of sec -on da ry grow th s.

A NA TO MIC CO NS ID ERA TION SThe pen iton ea l cav ity is sub d iv ided by

pen iton ea l refle c tion s an d m esen te ric a t-ta chm en ts in to sev e ra l com pa rtm en ts an drece sses (F ig . i). M ost o f th ese are an a-tom ica lly con tinu ou s , e ithe r d irec tly o r in -direct ly.

T h e m a jo r b a rrier d iv id ing the abd om -in al cav ity is the tra nsverse m esoco lo n . B e-low th is , th e ob liqu ely o rien ted sm a ll bow e lmesen te r y d iv ide s the in fram eso co lic spaceinto 2 com pa rtm en ts o f u nequ a l s ize : ther igh t an d le ft in fra co lic sp aces . The sm a llbow el m esen te ry itse lf is o f a ch aracten is -tic a lly ru ffled na tu re . It can b e likened to ase ries o f fan -like ex ten s ion s from th e ro o to f the m esen te ry . It is th is fea tu re tha tcon tribu te s to the cu rv atu re o f th e 1001)5

l lG . I . Po ste rio r p er iton e l re flec tion s an d int ra - ab-dom ina l spaces. IM = transverse m esoco lon ; PL= phren icoco l ic ligam en t; SB M = sm all bow elm esen te ry ; A C =attachm ent o f ascend in g co lon ;l)C=a ttachm en t of d escend ing colon ; SM =s ig-m oid m eso co lon ; r= rec tum ; b=urina ry b ladder;R IC = righ t in fraco lic sp ace ; L IC = le ft in fr ac olicspace; R PG = righ t paraco lic g u tte r; IPG = le ftpa raco lic gu tter .

of sm all b ow el. M ultip le in trapen ito nealrecesses a re thu s fo rm ed w ith in the re f lec -tio ns of the sm all bow e l m esen te rv . I tsm ain ax is , neverthe less, is d irec ted tow ardthe righ t low e r quad ran t in re la tion to th ete rm in al ileum and cecum . The rig h t in -fraco lic space te rm ina tes a t th eir junc tion .The le ft in fra co lic space is ana tom ica llyop en to tile pe lv is to th e righ t o f th e m id -line ; tow ard the lef t, it is restric ted f romcon t inu i ty w ith the pe lv ic cav it by th es igm oid m esoco lon .

Th e r igh t an d le ft pa ra co lic gu tters ar ela te ra l to th e attachm en ts o f th e p en -tonea l ref lectio ns o f tile a scen d ing and de -scend ing Co lon . Th ey rep re sen t po ten tial


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B

20 0 Morton A. Meyers SEPTEM BER , 1973

FIG . 2 . Sag itta l d iag ram o f rela tion sh ips of pouch o fDoug la s , the low er con tinua tion of th e peritonea lcav i ty be tween th e rec tosigm o id and the u rin a ryb ladd er (B ).

comm unica tion s b etw een the low er ab -dom en and p elv is be low , w ith th e sup ra-m esoco lic a rea abo ve . O n th e le ft, how ev er,the ph ren icoco lic lig am en t pa rtia lly sep -ara tes the pa raco lic gu tte r from th e pen -sp len ic (le f t su bph ren ic ) space. Th is liga -m en t ex tend s from the sp len ic flexu re o fthe co lo n to th e d iaph ragm a t th e leve lof the eleventh rib.8

In the sup ine po s itio n , the pelvis is th em o st d ep en den t p o rtion o f the pe rito nealcav ity . Its com partm en ts inc lude the m id -line cu l-de -sac o r pouch o f D oug las (recto -vag in al p ou ch in th e fem ale and recto -ve s ica l po uch in th e m a le ) an d the la te ra lpa rav es ic a l rece sse s . T he low e r ex tens io no f the pen ito nea l re flec tio ns com p ris ing th e

po uch of D oug la s p ro jec ts gene ra lly a t thelev el o f th e low er seco nd to up pe r fo u rthsac ral s egm en t (F ig . 2) . This va riab il ityis de term in ed by th e dev elo pm en ta l fix a-tion of the p en ito neum to D enonv illie rs fa sc ia (recto vag ina l o r rec tovesica l sep tum )and th e d eg ree o f d isten tion o f the u rin aryb lad de r an d rec tum .7 T h e lev el is a lso au se fu l lan dm ark to d em arcate the ju nc tionb etw een the rectum and th e s igm o id co lo n .T he v en tra l su rfa ce o f th e re cto s igm oidjun ctio n thu s fa ce s th e po uch of D oug la s .

RESULTSD YN A M IC RO ENTG ENO G RA PH IC 0 BSERV AT IO N S

F lu id in the in fram eso co lic com pan t-.m ent p refe ren tia lly seeks th e pe lv ic cav ity .F rom th e le ft in fraco lic space , flow is d ire c ta lon g the righ t s ide o f the rec tum . Som ef lu id is tem pora rily a rres ted a long th esuperio r p lane of the sigm oid m esoco lon bu tg radu ally chann els in to the p elv is . F romth e n ig h t in fraco lic sp ace , sp read occu rs ina serie s o f m ino r ca scade s on rivu le ts a lon gth e rece sse s o f the sm all b ow e l m esen tery .It is n o t un til a po o l is fo rm ed at th e ap ex ,a t the te rm ina tion of the ileum w ith thec e c um , tha t som e beg in s to o ve rf low in toth e pe lv is. T he pou ch o f D oug la s is firs tf i lled , and then sym m etric a lly the la tera lp an avesica l recesses (F ig . 3 ).

F rom th is p o in t th e flu id ascen ds b o thpa raco lic gu tte rs . P assage up the sh a llow erle f t on e is slow and w eak , and cep ha ladex ten s ion is l im ited b y th e p h ren ico co licl igam en t. T he m ajo r flow from the pe lv isis U p th e n igh t pa raco lic g u tte r (F ig . 4 ) .T h is th en p ro gre sse s to the righ t subh epa ticand subphren ic sp aces. D irec t passageac ro ss the m id lin e to the lef t su bph ren icspace is p rev en ted b y th e fa lc ifo rm lig a-m en t.

The righ t p a ra co lic g u tte r serv es a lso a sthe m a in comm unicatio n from the u ppe rto th e low e r abd om ina l C om pa rtm en ts .F ree ly m ovab le f lu id co llec ting in the n ig h tup pe r qu adran t a lso con tin ues to be re-d irected d ow nw ard alo ng th is chann e l tothe pe lv is.

F ou r p redom inan t s ite s a re th e refo re


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4-,

%O L . 119, No . i In tra -A bdom in al M alig nan t S eed in g 20 1

c lea r ly iden tified as th e p refe ren tia l, re -p ea ted , o n a rres ted flow o f in trap en ito nealf lu id : (i) th e pe lv ic cav ity , pa rticu la rly th ep ouch o f D oug las ; (2 ) th e n ig h t low erq uad ran t a t th e term in ation o f th e sm a llbow el m esen terv ; ( the su pe rio r a specto fthe s igm oid m esoco lo n ; and ( ) th e righ tpa raco lic g u tte r. T h ese pa thw ays are il-lu str at ed in F ig ur e 5.

ANALYS IS O F C LIN IC A l. C ASES O F INTRA PER I-TONEAL M AL IGNANT SEED ING

Tab le I s um m ar iz es th e m a jo r ana tom icfeatu re s o f in tn ap eriton ea l seed in g in th isser ies . The prim ary m a lign an c ies aro se inth e ov ary , panc rea s , s tom ach an d co lon .It is apparen t tha t, rega rd less o f the p n i-m ary orig in o f the n eop la sm , 4 d isc retesi tes o f seed ed m eta s ta se s w ere enco un-t ened :

(I ) Pouch o fD oug la s . Seed in g a t th is s itew as the m ost comm on , o ccu rrin g in 6 pe rcen t. O n b arium en em a stu dy , th is is re-vealed by a cha rac te ris tic pa tte rn o f f ixedpa ral le l fo ld s o n a nodu la r in den ta tion uponthe v en tra l a spec t o f the rec to s igm o idjunc tion (F ig . 6 ). T h is chang e re flects theco a lescen ce o f dep os its w ith a den se fib ro usreact ion .

(2 ) R igh t low er quad ran t. Seeded de -pos its in the low e r end of th e righ t in fra -co lic sp ace a lo ng the roo t o fthe sm a ll bow e l

Fic . 3. Supine po sitio n . In traperito nea l op aq ue co n-t rast m ateria l fir st gravitate s to th e p elv ic cav ity ,filling th e po uch of D oug la s and the 2 paraves ica lrecesses .

1 1G . 4 . Sup in e pos ition . In traperitonea l opaq ue con -tra s t flu id fills the p elv ic cav ity (PC ) and thenex tends cepha lad a long the righ t paraco lic g u tte r.

m esen te rv w ere c lin ica lly iden tifiab le b the ir d isp la cem en t of d ista l ile a l lo ops ,perhaps w ith p re ssu re e ffec ts a lso up on th em ed ia l con tou r o f the cecum and ascen d-in g co lo n . A t tim es, m ultip le g row thsor ien ted alo ng th is ax is w ith in tile term in alrecesse s o f the m esen te r m ay d isp lacesm a ll b ow e l loop s in a characterist ic scal-loped-cnescen u t pa ttern (F ig . 7 ). E x ten sived esm op la stic reac tion m ax f ix and angu la teilea l loo ps tow ard the sm a ll 1 )ow e l m esenu-ten y (F ig . 8 ) . T h is lo ca liza tion in the righ tl ower quadran t was p re sen t in 41 pe r cen to f the cases o f in tra l)en iton eal seed ing .

(3 ) S igm oid co lon . Lodgmen t an dg row th o f d epos its a rres ted alo ng the b a r-n ie r o f the s igm o id m esoco lon in the le ftlow er q uad ran t re su lted in cha racte ris ticchang es localized to th e sup erio r bo rde r


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20 4 M orton A . M eye rs SEPTEMBER , 19 73

4 foc i o ccu rred o n ly 6 tim es in th e 3 p atien ts . T he se inc lu ded 3 in s tance s o fm e tas ta ses to the tran sve rse and de scen d -in g co lon in 3 cases o f ov ar ian carc inom a,an d 2 in stances o f m e tasta se s to theje jun um and to the sp len ic flex u re o f th eco lon in 2 ca ses o f p rim a ry carc in om a ofth e co lo n . T he se d ispa ra te s ite s m ay h av eb een rela ted to adh es io ns from prev iou sabd om in al op era tio ns .

D ISCUSS IONFluoroscop ic and roen tgen o bse rv atio ns

clea rly and co nsisten tly d em on stra te tha tin trap en ito neal flu id , ra th e r than be ings ta t ic , con tin ua lly fo llow s a c ircu la tio nth ro ug h the ab dom en . Its pa thw ays o f d is -tn ib u tion an d sequ en tia l sp read are d ep en -den t on m esen te ric refle c tion s an d p en ito nealrece sse s . T he transv erse m eso co lo n , sm a llbow e l m esen ten v , s igm o id m eso co lo n , an dth e p en ito neal a tta chm en ts o f the a scen d -ing and descen d ing co lon se rv e as w a ter-sheds d irec tin g the flow of in trapen iton ea lfluid. The fo rce o f g rav ity op era te s to p oo lpen i tonea l flu id in d ep en den t p en ito nealrece sse s . M ost no tab le o f th ese is th e pe lv iccav ity , pa r ticu lar ly the pou ch o f D oug la s.Th is is th e m o st c aud al an d pos te rio r ex -ten s ion o f the pen itonea l cav ity . O the rco nsp icu ou s d ep en den t re cesses in the in -fram esoco lic po rtion o f the abd om en ,pa rticu la r ly in the sup in e p osition , a re thepo ck ets a lo ng th e sm all bow e l m esen teny ,th e apex o f the righ t in fn aco lic sp ace , th etro ug h alo ng th e ceph alad m arg in o f th esigm oid m esoco lon , an d th e n igh t panaco licgu t ter .

Egre ss from th e p elv is u pw a rd is no t afunc t ion sim p ly of ov erflow . F lu id sun-m oun ts the sacra l p rom on to ry and flan km usc le s to ex tend upw ard , w he the r thepa tien t is h o rizon ta l o r ere c t. In an e ffo rt toun de rstan d th e sp read o f in fec tio n , A u tio firs t docum en ted the in trapen ito nea l ex -tensio n of rad iog raph ic co n tras t m ed iumin to th e upp e r ab dom in a l re cesse s ev en inth e ere c t po si tion . T en cc . o f con tra stm edium w as in trodu ced in to th e ileo ceca l,pa raceca l an d pa rad uodena l reg io ns o f

38 pa tien ts in con nection w ith ap pend ec -tom y on cho le cv s tec tom v . It w as fo un dtha t the con tra st m ed ium m oved bo thdow n in to th e p elv is an d up in to th e su b -ph nen ic sp ace , vi a th e 2-w ay avenue of then igh t pa raco lic gu tte r. In ad d ition to thean atom ic pa thw ays an d ac tio n o f g rav ity ,varia tion s in in tnaperitonea l p ressu re alsode te rm in e the d istribu tion o f pen ito nea lflu id . Th e hyd ro static p re ssu re o f the con-ten ts o f the abdom ina l cav ity toge the r w iththe flex ib ili ty o f a po rtion o f the abd om in alw alls de term in e, fo r th e m o st pan t, thepressu re w ith in the ab dom ina l cav ity .O verho lt1 2 d em on stra ted in an im als tha tthe hyd ro sta tic p re ssu re is low er in th esub d iaphragm a tic reg ion than e ls ew here inthe ab dom en and tha t the p ressu re v arie sw ith re sp ira tio n . T he in trape rito neal pn es_su re in th e upp er abd om en is su ba tm o s-ph en ic an d dec rea ses fu rthe r du ring in -sp ina t ion . Th is nega tive subd iaphragm a ticp re ssu re and its rela tion to b reath ing ism ain tain ed in th e ho rizon tal on erect p osi-flo n . Th is is exp la ined b y the o u tw ardm ovem en t o f the n ibs du ring insp ira t ionw h ich en la rge s th e sp ace in the up pe r ab -dom en m o re th an it is dec rea sed by thedescen t o f the d iaph ragm . S a lk in 4 su bse-qu en tly co n firm ed th ese o bserv ation s inh um ans , n o tin g in a se rie s o f o case s th a tm ost sh ow ed an in tnapen iton eal p re ssu refrom 0 to -3 0 mm . w a ter and tha t the p re s-su re is le ss in the ep igastr ium than in thehypogas tn ium . D nye6 reco rded tha t in th euprigh t po sition pre ssu re in th e low er ab -dom en is a lm ost 3 tim es as g rea t as in th esup in e p osition . T hese p re ssu re d ifferencesw ith po s itio na l and resp ira to ry va ria tio nsh av e been con firm ed by o th ers .23

Su rp ris in g ly few obse rva tions h av e beenm ade in th e lite ra tu re reg a rd in g th e d is -tn ibu tion o f in trapen ito nea l seed ing . In -te re st has ap pa ren tly cen tered o n ly on th emos t c lin ica lly ev iden t site , i.e., Blumensshe lf w h ich rep resen ts a co ale scen ce o f d e-pos its w ith a d en se fib rous reac tion in th epouch o f D oug las.7 F irst described in1909 , it w as n o t un til 1939 tha t B acon2pub lish ed a se rie s o f 22 cases o f ex tra-


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VO L . 1 19 , N o . I Intra-Abdominal Malignant Seeding 20 5

re cta l m etas ta tic m a lig nancy sim u la tingp rim ary ca rcin om a o f the rec tum . In1941 , Buie et al.5 rep o rted a 5 y ear se rie sfrom the M ayo C lin ic co ns is tin g o f 25 4ca se s o f secon da ry sh elf tum o rs . T heyno ted tha t the m ost com m on causes o fex tra rec ta l m asses am ong w om en w ere le -s io ns o f the gen ita l sy s tem , an d am ongm en le sion s o f th e g as tro in te s tin al tra c t . In1955 , H u ltbo rn and a sso cia te s7 con clud edtha t the fa cto r e ssen tia l to th e d ev e lop -m en t o f a sh elf tum or is p ath o log ic fix at iono f th e u pp erm ost pa rt o f the re c tog en ita lsep tum (D enonv il lie rs fa scia ). O bse rv a -tio ns o n th e d is trib u tio n o f in trapen iton ea lseeded m a lig nanc ie s o the r th an the p ou chof D oug las are no tab ly la ck ing . W illisc la ss ic w o rk o n th e sp read o f neop la sm s6doe s no t sub s tan tia lly fu rthe r u nd ers tand -in g o f transco e lom ic sp read .

It is a ccep ted th a t in b reak ing th rou ghin to the p eriton ea l c av ity , a p rim a ry n eo -p la sm or even its in tra-abd om in al lym phnod e m e ta stase s can sh ed ce lls in to thea scit ic flu id ind uced . O ur o bse rva tio ns in -d ic ate th a t it then seed s depo s its a lo ng thep athw ay s o f sp read and lo caliza tio n o fin trape riton ea l flu id . T he com m ones t s ite so f lod gm en t an d g row th o f seeded m e ta s-ta ses clea rly co rre la te w ith th e p atte rn s o fflow of a sci tic flu id . F o u r specific s ite s a reevident: (i) the pouch of Douglas at there cto s igm o id lev el; (2 ) the righ t low e rq uad ran t a t th e low e r en d of the sm allbow e l m esen te ry ; (3 ) th e left low e r qu ad -ran t a lon g th e sup erio r bo rd e r o f th e sig -m o id m eso co lon an d co lo n ; and ( th erigh t pa ra co lic g u tter la te ra l to the cecumand ascend ing co lo n . T h e d eg ree o f asc ite sneed no t b e g rea t. T hean de r et al.5 foundch arac teris tic chang es in the rec to sigm oidto be roen tg en o log ica lly id en tifiab le in iop er cen t o f c ase s o f asc ite s se co nd ary tope rito neal ca rc inom a to sis. In o u r m a teria l,th e fin d in g w as p resen t in 6 p er cen t o fth ose ca ses w ith in vo lvem en t o f the pen -to neal c av ity a t s ing le o r m u ltip le si tes , re -g ard le ss o f th e deg ree o f asc ite s. L o ca liz a -tio n in the rig h t low er q uad ran t w as c lea rlyid en tifiab le in 4 p er c en t, in th e s igm oid

m eso co lo n in 21 pen cen t, and in the rig h tp ara co lic gu tte r in 8 pe r cen t.

T he fact th at depo s itio n an d g row th o fseco nd ari ly seeded neop la sm s in the ab -d om en is depend en t up on th e na tu ra l flowo f a sc ite s w ith in th e pe riton eal recesse s isn o t o n ly o fd iagn os tic s ig n ific ance b u t m aya lso have the rap eu tic im p lic a tion s . F u rthe re ffo rts in th e con tro l o f flow o f asc iticflu id m ig h t be deve lop ed to loca liz e seededd ep os its fo r m ore effe c tive rad io th erapy orch emo th e r ap y .

SUM M ARY AND CONC LUSION S

The d is tribu tion o f in trapen ito nea l m alig -nan t se ed in g cle an ly co rre la tes w ith th ep athw ay s o f flow o f a scit ic flu id .

Fou r p redom inan t sites o f seeded m eta s-tase s a re id en tified : (i ) the pouch ofDoug la s a t the rec tosigm oid lev el; (2) th erigh t low e r qu ad ran t a t th e low er end ofthe sm a ll bow e l m esen ten v ; (, the le ftlow e r qu ad ran t a lo ng th e sup e rio r b o rd ero f the s igm oid m esoco lon and co lon ; an d(4 ) the rig h t p araco lic g u tte r late ral to thececum and ascend ing co lon . It is a t the ses ite s th at th e p refe ren tia l, rep ea ted o rarre sted flow ofin trap en itonea l f lu id o ccu rs .

It is conc lud ed tha t depos ition andg row th o f seco nd ari ly seeded neop la sm s inthe ab dom en are d ep end en t u po n th e n at-u ra l flow o f a sci tes w ith in th e p en ito nea lrecesses .D epartm en t o f R ad iologyT he N ew Y ork H osp ita l and M em oria l

H ospita l for C an cer and A llied D iseasesC orn ell Un iversi ty M edica l C en te r52 5 Eas t 68 th S tree tN ew Yo rk , N ew Y ork ioo2I

REFERENCESI. A UT IO , V . Spread of in traperitonea l in fec tion :

stud ies w ith ro en tgen co n trast m ed ium . Ac tac hi r. s ca nd in av ., i 964 , S upp l. 32 I , 1-3 I.

2. B AC ON , H . E . Ex trarec ta l m etas ta tic m alignancysim ula ting p rim ary carcin om a of rec tum .New York 7. Med., 1939 ,39 , 2267 -2273 .

3 . BA NY A I, A . L . P neum op er iton eum T rea tm en t.C . V . M osby C om pany , S t. L ou is, 1946 .

4 . BLUM ER , G . R ec ta l she lf: neg lec ted rec tal s ig no fva lu e in d iagn osis o fo bscu re m alignant and


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20 6 M orto n A . M eye rs SEPTEM BER , 197 3

in flamma tory d isea se w ith in abd om en . AlbanyM . Ann . , 3909 ,30 , 36 1 .

5. BU IE , L . A ., J A CKMAN , R. J. , an d VICKERS ,P . M . E xtra rec tal m asses cau sed by tum o rs ofrec to -u te rine o r recto vesica l sp ace . :7 .A.M.A. ,1941 , 117 , 167- 169 .

6. DRY E , J. C . In traperitonea l p ressu re in hum an .Surg ., G yn ec. & O bst., 1948 , 87 , 472-475.

7. HU LTBORN , K . A ., MORALE S , 0 ., and RO M A N US ,R . So -ca lled sh e lf tum our o f rec tum . Adarad io ! . , 1955 , S uppl. 1 24 .

8 . M EY ERS, M . A . R oen tgen sign ificance o f phren i-coco l ic l igamen t . Rad io logy , 1970 , 9 5, 5 39 -5 45 .

9. M EY ERS, M . A . Spread and localiza tio n of acu tei n traperi tonea l efiT us ions . Rad io logy , i 970 , 95 ,547-554 .

10 . M EY ERS, M . A ., an d MCSWEENEY , J. Seco nd a ryneop la sm s of bowe l . Rad io /og , 1972 , 105 ,

I I. IE YE R5, 1\i. ,A . Peritoneog raphy : norm al andpatho lo g ic anatom y . AM . J. ROEN TGENOL . ,RAD . IH ERA PY & NUCLEAR M ED ., 1973, 117 ,353 -3 65 .

12 . O V ERHO I,T , R . H . In traperitonea l p ressu re .A rch . S iirg ., 1931, 22 , 691-703 .

33 . OvERHOI ,T , R . H ., and DONCHE S S , J. C . S ub-ph ren ic abscess. New Eng land 7 . Med . , 1935 ,213, 294-301 .

1 4 . SA LK IN , I) . In traabdom ina l p ressu re an d itsregula t ion. Am . R ev . T uberc ., 1934 , 30 , 436-457 .

15 . IH EA ND ER , G ., \V EH L IN , L ., and LA N GELA ND ,P. D eform ation o f rec to sigm oid jun ction inpen tonea l carcino mato sis. Ada ra d io !. (Diag .) ,1963, 1, 1071-1076.

i6 . WILL I S , R . A . T he Sp read of Ium ours in theHum a n H od y . Second ed i tio n . But t e rwor th ,London , 1952 .

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