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Peritoneal Calcification: Causes and

Distinguishing Features on CT
Atul Agarwal1 OBJECTIVE. We undertook this study to determine the causes of peritoneal calcification
Benjamin M. Yeh seen on CT and to investigate which CT features distinguish benign from malignant perito-
Richard S. Breiman neal calcification.
Aliya Qayyum MATERIALS AND METHODS. Seventeen patients with peritoneal calcification were
identified through retrospective review of reports from 74,765 abdominopelvic CT examina-
Fergus V. Coakley
tions performed during a 7-year period. We determined the cause of peritoneal calcification
by examining medical and histopathologic records. Calcification morphology was classified
as nodular or sheetlike on the basis of the consensus interpretation by two independent radiol-
ogists. The radiologists also recorded the presence or absence of associated soft-tissue com-
ponents or lymph node calcification. The association between the CT findings and the cause
of calcification was assessed using chi-square analysis.
RESULTS. Peritoneal calcification was due to peritoneal dialysis (n = 4), prior peritonitis
(n = 3), cryptogenic origin (n = 1), or peritoneal spread of ovarian carcinoma (n = 9). Sheet-
like calcification was more common in patients with benign calcification (seven of eight pa-
tients) than in those with malignant calcification (two of nine patients, p < 0.05). Nodal
calcification was seen only in patients with malignant calcification (five of nine patients vs
none of eight, p < 0.05).
CONCLUSION. Common causes of peritoneal calcification are dialysis, prior peritoni-
tis, or ovarian cancer; sheetlike calcification indicates a benign cause, whereas associated
lymph node calcification strongly suggests malignancy.

T he detection of peritoneal calcifi-

cation on CT is rare but potentially
of major clinical importance be-
cause such findings have been associated with
investigate which CT features distinguish be-
nign from malignant peritoneal calcification.

primary and secondary peritoneal malignan- Materials and Methods

cies [1, 2], as well as with benign causes such
as sclerosing peritonitis due to peritoneal dial-
ysis [3, 4], peritoneal tuberculosis [5], prior
meconium peritonitis [6], hyperparathyroid-
ism [7], Pneumocystis carinii infection [8],
and postsurgical heterotopic ossification [9].
Prior case reports and series describing perito-
neal calcification have focused on specific sin-
Received May 30, 2003; accepted after revision
August 21, 2003. gle causes, but the relative frequency of these
1
All authors: Department of Radiology, University of entities and the potential distinguishing CT
California San Francisco, 505 Parnassus Ave., M372, features of benign and malignant calcification
San Francisco, CA 94143-0628. Address correspondence
have not been studied in a comparative fash-
to B. M. Yeh.
ion, although such information would be of
AJR 2004;182:441–445
value to the interpreting radiologist. Therefore,
0361–803X/04/1822–441 we undertook this study to determine the cause
© American Roentgen Ray Society of peritoneal calcification seen on CT and to
Subjects
Ours was a retrospective single-institution study
approved by our institutional review board. In-
formed consent was not required. We performed a
computerized search of our radiology information
system (IDXrad software, version 9.7.1, IDX Sys-
tems, Burlington, VT) for the period January 1995
to September 2002 to identify patients whose ab-
dominopelvic CT reports (74,765 examinations)
contained the character strings “periton” and “calc.”
An attending radiologist with subspecialist experi-
ence in abdominal imaging reviewed the CT studies
(n = 59) identified in this search to select those
cases with definite peritoneal calcification. Perito-
neal calcification was defined as the presence of one
or more lesions showing CT attenuation similar to
that of bone in an unequivocally intraperitoneal lo-

AJR:182, February 2004 441


cation such as the perihepatic space, perisplenic
space, paracolic gutters, Morison’s pouch, omental
surface, and pouch of Douglas. Many cases were
associated with ascites, which frequently facilitated
localizing a calcified lesion as intraperitoneal.
On the basis of this review, 17 patients were con-
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sidered to have had peritoneal calcification. The fi-
nal study group consisted of 14 women and three
men whose mean age was 54 years (range, 30–83
years). To determine the cause of peritoneal calcifi-
cation in these patients, two of the authors reviewed
all available medical records and recorded pertinent
histopathologic and clinical findings, including
prior surgery, peritoneal dialysis, peritonitis, or con-
firmed malignancy (before or after the CT examina-
tion). Calcification was considered benign if
patients had a history of peritoneal calcification
known to have a benign cause and no histopatho-
logic evidence of peritoneal malignancy. Calcifica-
tion was considered malignant if patients had
proven peritoneal carcinomatosis.
CT Technique
CT scans were obtained using helical CT scanners
(LightSpeed [n = 8 patients] or HiSpeed [n = 9 pa-
tients] General Electric Medical Systems, Milwaukee,
WI). Sixteen patients received 150 mL IV iohexol
(Omnipaque 350, Nycomed Amersham, Princeton,
NJ). Sixteen patients received 800 mL oral diatrizoate
meglumine (Hypaque, Nycomed Amersham). Two
patients received 250 mL rectal diatrizoate meglu-
mine (Hypaque). Slice collimation was 5 (n = 8), 7
(n = 6), 8 (n = 1), or 10 (n = 2) mm. All images were
contiguous. Indications for CT scanning were evalua-
tion of abdominal symptoms (n = 7) or of known or
suspected tumor (n = 10). Abdominal symptoms con-
sisted of pain, nausea, or vomiting.
Fig. 1.—84-year-old woman with serous ovarian adenocarcinoma.
A, IV and oral contrast–enhanced abdominal CT scan shows large nodular calcifications (arrowheads) in left side of abdomen.
B, Pelvic CT scan shows calcified left inguinal lymph node (arrow). Pelvic cavity is largely replaced by large solid and cystic calcified mass.
442
Agarwal et al.
Image Interpretation and Analysis
Two attending radiologists reviewed all CT
scans and made interpretations by consensus, un-
aware of clinical or histopathologic findings. The
interpreters classified calcification morphology as
nodular (circumscribed and focal) or sheetlike (flat,
curvilinear, and extending along a peritoneal
plane). Both patterns were recorded if simulta-
neously present in the same patient. The interpret-
ers also recorded the presence or absence of
associated soft-tissue components and lymph node
calcification (Figs. 1–3). Soft-tissue components
were considered to be present if structures with CT
densities of between 20 and 80 H were observed as
being contiguous to the calcification without an in-
tervening fat plane and separate from adjacent or-
gans. The association between CT findings and
cause was assessed using chi-square analysis. A p
value less than 0.05 was considered to be significant.
Results
Causes of Peritoneal Calcification
Eight patients had benign peritoneal calcifi-
cation related to peritoneal dialysis (n = 4),
peritonitis (n = 3), or cryptogenic origin (n =
1). Of the four patients who had peritoneal cal-
cification stemming from peritoneal dialysis,
three had documented histories of both dialy-
sis-related peritonitis and abdominal surger-
ies—cholecystectomy and ventral hernia
repair with omentectomy in one patient, chole-
cystectomy in another, and partial nephrec-
tomy and two failed renal transplantations in
the third. The partial nephrectomy in this latter
A B
patient was performed to treat a low-grade 1.5-
cm renal cell carcinoma with no evidence of
metastatic spread. For each of these patients,
the extent of peritoneal calcification was
greater than that of the expected surgical field.
The three patients with peritoneal calcifica-
tion resulting from prior peritonitis also had
complex histories. One had a history of multi-
ple abdominal abscesses and enterocutaneous
fistulas after undergoing a colectomy and co-
lostomy for perforating diverticulitis. One had
a history of pancreatitis, endometriosis, chole-
cystectomy, appendectomy, hysterectomy, bi-
lateral salpingo-oophorectomy, and multiple
laparotomies for an adhesive small-bowel ob-
struction. The third patient had a history of
cholecystectomy and duodenal resection for a
duodenal adenoma. The patient with benign
cryptogenic peritoneal calcification exhibited
perihepatic calcifications on CT and had a his-
tory of renal transplantation for focal and seg-
mental glomerulosclerosis but had no history
of peritonitis, peritoneal dialysis, other abdom-
inopelvic surgery, or malignancy.
Nine patients had malignant peritoneal calci-
fication. In eight of these patients, calcification
was due to peritoneal spread of ovarian cancer
and in one, it was due to primary papillary se-
rous peritoneal carcinoma. Five of the patients
with ovarian cancer had serous cystadenocarci-
noma; for three patients, the histopathologic
type was unspecified. Lymph node calcification
was seen in five (56%) of these nine patients.
Eight of the patients had undergone total ab-
AJR:182, February 2004
 CT of Peritoneal Calcification
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A B
Fig. 2.—30-year-old woman who was undergoing continuous ambulatory peritoneal dialysis.
A, IV and oral contrast–enhanced abdominal CT shows sheetlike calcification around spleen (arrow) and liver (arrowheads) extending into fissure for ligamentum teres.
Splenic arterial calcification is present.
B, Pelvic CT scan shows peritoneal dialysis catheter (white arrow) as well as sheetlike calcification surrounding bowel and mesentery (arrowheads), associated with dif-
fuse bowel wall thickening and soft-tissue components (black arrow).

dominal hysterectomy, bilateral salpingo-
oophorectomy, omentectomy, and lymph node
dissection before undergoing CT, and three had
received chemotherapy. One patient with malig-
nant peritoneal calcification had previously re-
ceived radiation therapy, and none of the
patients with benign peritoneal calcification had
previously received radiation therapy.
Distinction Between Benign and Malignant Peritoneal
Calcification
The clinical and CT characteristics of pa-
tients with benign and malignant peritoneal
calcification are shown in Table 1. Sheetlike
calcification was significantly more common
(p < 0.05) in patients with benign calcification
(seven of eight patients) than in those with ma-
lignant calcification (two of nine). Nodal calci-
fication was seen only in patients with
malignant calcification (five of nine vs none of
eight, p < 0.05). Combining findings of sheet-
like calcifications and absence of nodes or
other permutations of findings was not helpful
in distinguishing patients with benign calcifi-
cation from those with malignant calcification.

A B

Fig. 3.—46-year-old woman with ovarian papillary serous adenocarcinoma.

A, IV and oral contrast–enhanced CT scan shows several nodular calcifications (arrows) in lesser sac and fissure for ligamentum teres.
B, Pelvic CT scan shows calcified solid and cystic mass in cul-de-sac caused by disease recurrence.

AJR:182, February 2004 443


Clinical and CT Characteristics in 17 Patients with Benign Versus Malignant
TABLE 1
Peritoneal Calcification
Parameter
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Patients
Mean age (yr)
Sex ratio (men:women)
Clinical history
Peritoneal dialysis
Peritoneal infection, inflammation, or surgery
Ovarian or primary peritoneal cancer
CT features
Nodular calcification
Sheetlike calcification
Soft-tissue component
Nodal calcifications
Ascites
Note.—NS = not significant.
Discussion
Peritoneal calcification is occasionally seen
on CT of the abdomen and pelvis and has many
different causes [1–9]. To our knowledge, dis-
tinguishing features of these calcifications in re-
gard to causation have not been previously
evaluated. In this study, we sought to find fea-
tures of peritoneal calcification that may sug-
gest either a benign or malignant cause. In our
series, we found that peritoneal calcification as-
sociated with calcified lymph nodes was signifi-
cantly more likely to be seen in malignancy
than in benign disease and that a sheetlike ap-
pearance of peritoneal calcification was associ-
ated significantly more frequently with benign
disease. However, although sheetlike peritoneal
calcification suggests a benign rather than ma-
lignant cause, this rule should also be applied
with caution because a substantial portion (2/9
or 22%) of the patients with malignant calcifica-
tion also had sheetlike calcification. Other char-
acteristics of peritoneal calcification, including
location, size, extent, and association with soft-
tissue masses, were not helpful in distinguishing
benign from malignant causation.
Peritoneal calcification is caused by two pri-
mary mechanisms. Metastatic calcification may
be a result of a systemic mineral imbalance in
entities such as uremia or hyperparathyroidism,
whereas dystrophic calcification may result
from tissue injury, aging, or disease, including
malignancy [10]. It is not surprising that malig-
nant disease is more likely to cause lymph node
involvement, and hence lymph node calcifica-
tion, than is renal failure, hyperparathyroidism,
444
Agarwal et al.
Cause of Peritoneal Calcification
Benign Malignant p our series is not likely to be due to merely a dis-
(n = 8) (n = 9)
50 58 NS
3:5 0:9 NS
4 0 NS
7 8 NS
0 9 < 0.05
8 9 NS
7 2 < 0.05
4 7 NS
0 5 < 0.05
4 2 NS
or postsurgical changes. However, it is surpris-
ing that we found lymph node calcification as-
sociated only with malignancy and not with
infectious or inflammatory causes such as tu-
berculosis or fungal infection. This finding may
reflect, to some extent, the patient population at
our institution or may reflect the rarity of perito-
neal calcification in infectious calcified nodal
disease. This notion is supported by several
large studies of abdominal tuberculosis that have
reported CT findings of calcified nodal disease
but have not reported any case of peritoneal calci-
fication [11–16]. We are aware of only three case
reports of peritoneal calcification associated with
tuberculosis, and in each of these case reports, the
association with tuberculosis was made by exclu-
sion: no acid-fast bacteria or granulomas were
identified at histology in the calcified peritoneal
deposits of these patients [5, 17, 18].
We did not identify peritoneal calcification
associated with any malignancy apart from ova-
rian cancer or primary papillary serous perito-
neal carcinoma. Although some malignancies,
such as squamous cell lung cancer, renal cell
carcinoma, and melanoma, are known to induce
paraneoplastic hyperparathyroidism and hyper-
calcemia [19] and could conceivably mimic a
benign pattern of peritoneal calcification, we
did not observe such an occurrence. Other ma-
lignancies may also cause calcified peritoneal
carcinomatosis, colon cancer [20], and gastric
cancer [21], but we did not find such calcified
peritoneal masses in this series. Our institution
serves a large oncology population, but less than
20% of the CT examinations ordered by the on-
cology service are for gynecologic oncology
patients, and the lack of malignancies other than
ovarian or primary papillary serous peritoneal
carcinoma causing peritoneal calcification in
proportionate number of patients with ovarian
carcinoma at our hospital. The proportion of pa-
tients in our study with ovarian cancer, perito-
neal calcification, and concurrent calcified
lymph nodes (5/9 or 56%) was higher than that
reported by Mitchell et al. [1], who described
calcified lymph nodes in only one of six such
patients (17%). The apparent increased preva-
lence of calcified lymph nodes in our series may
reflect improvement in CT technology since
1986. Much like serous ovarian adenocarci-
noma, primary papillary serous peritoneal carci-
noma is known to cause calcified peritoneal
carcinomatosis and lymph node calcification
[2].
Meconium peritonitis is the most common
cause of peritoneal calcification and can cause
microscopic and macroscopic calcified deposits
with varied appearances [6, 22–24], but perito-
neal calcification associated with numerous
other entities has been described in several re-
ports. In one series, two of the three patients
with AIDS and extrapulmonary Pneumocystis
carinii infections had calcifications of multiple
lymph nodes; one of these two patients had con-
current small nodular calcifications of the pleu-
ral and peritoneal surfaces [8]. Three case
reports of diffuse nodular peritoneal calcified
deposits of varying sizes, all attributed to tuber-
culosis, were found at laparoscopy (n = 2) and
autopsy (n = 1) [5, 17, 18]. In one case report of
peritoneal mesothelioma, diffuse peritoneal cal-
cification was reported [25], whereas in another
case report of benign cystic peritoneal mesothe-
lioma, a large intraperitoneal cystic mass with
nodular calcifications was described [26]. A
case report of diffuse peritoneal amyloidosis de-
scribed omental and peritoneal thickening with
nodular calcifications as well as retroperitoneal
lymph node calcification [27].
Our study has a number of limitations.
Characteristics of our study population may
not allow our findings to be extrapolated to the
general population. Although none of our pa-
tients with benign peritoneal calcification had
lymph node calcification, none had a history
of tuberculosis or P. carinii infection, entities
that have been associated with calcification of
both lymph nodes and the peritoneum [5, 8].
Other noninfectious benign entities, such as
amyloid and systemic sclerosis, have also been
associated with calcified lymph nodes [28, 29]
and potentially the concurrent presence of
AJR:182, February 2004

such benign disease processes may cause peri-
toneal calcification to be misinterpreted as be-
ing of malignant origin. Our findings most
likely reflect the population of patients re-
ferred to our institution, an urban tertiary-care
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North American teaching hospital, and should
be extrapolated with caution in populations
where infectious causes of calcified lymph
nodes are more prevalent. For example, our in-
stitution supports a large kidney transplanta-
tion and oncology service, which possibly
contributed to a disproportionate number of
patients with peritoneal dialysis and malig-
nancy found with peritoneal calcification. An-
other limitation is that our study probably did
not include every case of peritoneal calcifica-
tion seen on CT in our hospital because the in-
terpreting radiologists may not have reported
incidental peritoneal calcifications, or if they
did, they may not have used words in their re-
port that would have been captured by our
character string search. In addition, the sensi-
tivity of CT in the detection of subtle calcifica-
tions may be limited because contrast material
was used in all CT examinations. A further
limitation is that among the patients included
in our study, eight of the nine patients with
malignant disease had previously undergone
intraabdominal surgery, which may have led to
the formation of peritoneal calcification with a
benign postsurgical cause.
Notwithstanding these limitations, we found
the common causes of peritoneal calcification
to be dialysis, prior peritonitis, or ovarian can-
cer. Sheetlike calcification suggests a benign
cause, whereas associated lymph node calcifica-
tion strongly suggests malignancy.
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