Mucinous Appendiceal Neoplasms: Preoperative MR Staging and Classification Compared with Surgical and Histopathologic Findings
Russell N. Low1,2,
Robert M. Barone3,
Jonathan M. Gurney1,2 and
Wayne D. Muller4
1 Sharp and Children's MRI Center, Sharp Memorial Hospital, 7901 Frost St., San
Diego, CA 92123.
2 Department of Radiology, Sharp Memorial Hospital, San Diego, CA.
3 Department of Surgical Oncology, Sharp Memorial Hospital, San Diego, CA.
4 Department of Pathology, Sharp Memorial Hospital, San Diego, CA.
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Fig. 1A —67-year-old woman with mucinous appendiceal neoplasm. Delayed
gadolinium-enhanced image shows marked enhancement (level 4) of bulky tumor
encasing stomach, spleen, and splenic flexure (long white arrows).
Enhancing right subphrenic tumor (short white arrows) and tumor in
superior recess of lesser sac (black arrow) are also noted. MRI
findings indicate peritoneal mucinous carcinomatosis tumor. Delayed
enhancement of cellular tumor on gadolinium-enhanced MR images markedly
improves tumor conspicuity in pseudomyxoma peritonei syndrome and
distinguishes tumor from nonenhancing mucin and ascites.
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Fig. 1B —67-year-old woman with mucinous appendiceal neoplasm. Coronal
gadolinium-enhanced image shows confluent bulky omental and left paracolic
tumor (long white arrows) surrounding splenic flexure and descending
colon. Diffuse enhancing mesenteric and small-bowel serosal tumor (short
thin white arrows) is present predicting incomplete surgical resection.
Right subphrenic tumor (thick white arrows) and tumor encasing
gastric antrum (black arrow) are also noted. Subsequent surgical
cytoreduction was incomplete.
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Fig. 1C —67-year-old woman with mucinous appendiceal neoplasm.
High-power microscopic view of mucin contains large aggregates of
well-differentiated adenocarcinoma. Specimen showed many tumor cells. Note
cytologic atypia (arrow). Findings are that of peritoneal mucinous
carcinomatosis tumor.
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Fig. 2A —81-year-old man with mucinous appendiceal neoplasm.
Fat-suppressed T2-weighted MR image shows right paracolic
high-signal-intensity mucin (arrow). T1-weighted image (not shown)
depicted similar right paracolic collection.
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Fig. 2B —81-year-old man with mucinous appendiceal neoplasm. Delayed
gadolinium-enhanced gradient-echo image depicts minimal (level 2) peripheral
enhancement (arrow) of mucinous epithelium. Central portion of
collection shows no enhancement. MRI findings correlate with disseminated
peritoneal adenomucinosis–type mucinous appendiceal neoplasm composed
almost entirely of mucin. No involvement of small-bowel mesentery or
small-bowel serosa was present.
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Fig. 2C —81-year-old man with mucinous appendiceal neoplasm.
Medium-power view shows columnar glandular epithelial cells with basally
oriented nuclei and mucinous cytoplasm (arrow). Neither cytologic
atypia nor mitotic activity is present. Adjacent abundant pink-staining mucin
and collagen are also noted. Findings are that of disseminated peritoneal
adenomucinosis tumor.
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Fig. 3A —77-year-old woman with mucinous appendiceal neoplasm.
T1-weighted MR image shows extensive complex mass (arrow) that is
interposed between stomach, liver, and spleen. Additional right subphrenic
material surrounds liver.
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Fig. 3B —77-year-old woman with mucinous appendiceal neoplasm.
T2-weighted image shows extensive complex mass (long arrows)
interposed between stomach, liver, and spleen. Additional right subphrenic
material (short arrow) surrounds liver.
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Fig. 3C —77-year-old woman with mucinous appendiceal neoplasm. Axial
delayed gadolinium-enhanced gradient-echo image through middle abdomen shows
bulky mesenteric mass (arrow) encasing mesenteric vessels.
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Fig. 3D —77-year-old woman with mucinous appendiceal neoplasm. Coronal
gadolinium-enhanced gradient-echo image shows confluent upper and large middle
abdominal mesenteric mass (long arrows). Right subphrenic tumor
(short arrow) is also noted. Note that degree of tumor enhancement is
less than that of liver parenchyma. Both observers recorded level 2
enhancement (less than liver parenchyma), which indicates disseminated
peritoneal adenomucinosis or intermediate-type tumor. Extensive mesenteric
tumor predicts incomplete surgical resection. At surgery, bulky diffuse
abdominal tumor was found encasing transverse colon, mesentery, and small
bowel. Cytoreduction was incomplete.
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Fig. 3E —77-year-old woman with mucinous appendiceal neoplasm.
Low-power microscopic view shows abundant central mucin (M) with surrounding
collagen and single layer of mucinous epithelial cells (arrow).
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Fig. 3F —77-year-old woman with mucinous appendiceal neoplasm.
Although most specimens had low-grade appearance, high-power microscopic view
shows focal area of adenocarcinoma (arrow) invading smooth muscle
(SM) of stomach wall. Findings are that of intermediate-type tumor.
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Fig. 4A —61-year-old woman with mucinous appendiceal neoplasm.
Unenhanced T1-weighted MR image shows 4-cm right paracolic mass
(arrow). Solid tumor and mucin cannot be distinguished on unenhanced
MRI.
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Fig. 4B —61-year-old woman with mucinous appendiceal neoplasm.
Unenhanced T2-weighted MR image shows 4-cm right paracolic mass
(arrow). Solid tumor and mucin cannot be distinguished on unenhanced
MR images.
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Fig. 4C —61-year-old woman with mucinous appendiceal neoplasm. Axial
delayed gadolinium-enhanced image shows marked enhancement of solid component
of tumor (long arrow); 4-cm mass (short arrow) contains
nonenhancing mucin centrally and rim of enhancing solid tumor.
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Fig. 4D —61-year-old woman with mucinous appendiceal neoplasm.
High-power microscopic view shows complex group of neoplastic cells with
marked cytologic atypia diagnostic of adenocarcinoma. Arrow is pointing at an
abnormal cell with enlarged nucleus having macronucleolus and high
nuclear-tocytoplasmic ratio. Findings are that of peritoneal mucinous
carcinomatosis tumor.
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Fig. 5 —64-year-old woman with mucinous appendiceal tumor. Delayed
gadolinium-enhanced spoiled gradient-echo MR image shows thin rim of
peritoneal tumor (arrow) adjacent to inferior right hepatic lobe.
Small-volume small-bowel serosal tumor found at laparotomy was not identified
on MR image by either observer. Surgical cytoreduction was complete.
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Copyright © 2008 by the American Roentgen Ray Society.
) and tumor-to-intravascular gadolinium signal (
). Measurements
of mean signal intensity were made on workstation by placing region of
interest over enhancing tumor, liver parenchyma, and abdominal aorta or
inferior vena cava.