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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 6  |  Issue : 1  |  Page : 92-93

Malignant peritoneal mesothelioma: A case report


1 Assistant Professor, Dept. of Gynecological Oncology
2 Professor & Head, Dept. of Pathology
3 Senior Resident
4 Professor & Head, Dept. of Gynecological Oncology

Date of Submission12-Jan-2020
Date of Acceptance16-Jan-2020
Date of Web Publication16-Nov-2020

Correspondence Address:
Sangeeta Pankaj
Prof. & Head, Dept. of Gynecological Oncology, SCI, IGIMS, Patna

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Source of Support: None, Conflict of Interest: None


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  Abstract 


Mesothelioma is a rare condition with 1 in 1 million incidences. Pleura being the commonest site followed by peritoneum. Malignant peritoneal mesothelioma (MPM) presents difficulties and delay in diagnosis due to non-specific symptoms. Here we present a case of 22 year old female who presented with the complaints of abdominal pain and distension. No history of asbestos exposure was reported. A lump was palpable on abdominal and pelvic examination. Computed tomography (CT) scan was suggestive of large solid tumour with fat stranding. Laparotomy was done and a solid mass lesion seen on left side mesentery attached to bowel. The mass was removed. Final diagnosis was possible with histopathological documentation of tumor characteristics, which were consistent with dictating a mesothelial origin.

Keywords: Malignant peritoneal mesothelioma, computed tomography, histopathological


How to cite this article:
Abhilashi K, Kumar B, Rani J, Kumari P, Kumari S, Pankaj S. Malignant peritoneal mesothelioma: A case report. J Indira Gandhi Inst Med Sci 2020;6:92-3

How to cite this URL:
Abhilashi K, Kumar B, Rani J, Kumari P, Kumari S, Pankaj S. Malignant peritoneal mesothelioma: A case report. J Indira Gandhi Inst Med Sci [serial online] 2020 [cited 2020 Nov 26];6:92-3. Available from: http://www.jigims.co.in/text.asp?2020/6/1/92/300751




  Introduction Top


Malignant mesothelioma is a rare malignancy arising from serosa, pleural surface (95.5%) being the commonest site while peritoneum (4%) the rare site. Other rarest sites are pericardium and tunica vaginalis of testes[1]. The epidemiologic data on malignant mesothelioma varies widely across countries. The highest rates are reported in some industrialized countries[2]. Asbestos is the most common carcinogen related to pleural mesothelioma, however only 33-50% of patients diagnosed with MPM report any known prior exposure to asbestos[3].

Common presentations of this rare malignant peritoneal mesothelioma are abdominal distension and/or pain, some cases present with ascites or palpable lump[4]. Some patients present with vague symptoms of weight loss, decreased appetite and fever. The diagnosis is difficult due to lack of specific symptoms and clinical findings.


  Case Report Top


A 22 years old woman presented to the gynecological oncology outdoor of IGIMS in June 2019 with complains of abdominal distension and pain for one month. There was a significant clinical history of hysterotomy with left cystectomy one year back in view of five months amenorrhoea with left ovarian cyst. The histopahological report of the cyst was suggestive of dysgerminoma. On clinical examination all systemic examinations were unremarkable except abdominal and vaginal examination. On abdominal examination a solid, mobile, non-tender lump with regular margin of 10cmx12cm size occupying the left iliac fossa and left lumbar area was present. On vaginal examination same lump was palpable through left fornix; uterus was felt separately and was of normal size. She came to us with a CECT report which showed a large lobulated dumbbell-shaped heterogeneously enhancing solid lesion of size 13x10.8x7.6cm in the mesentery of left lumbar and iliac fossa region with few necrotic changes and fat stranding. Her all routine blood tests reports were normal. The tumour marker report revealed increased level of CA-125 (72.1U/ml), AFP (175.8U/ml) and LDH (346U/L) whereas others were within normal range.

Patient was admitted; a pre anesthetic checkup was done and was taken for surgery. Laparotomy was performed and 14x12cm size left mesenteric cyst was found adhered to bowel which was removed and sent for histopathological evaluation. There were no other significant intraoperative findings except the absence of left side ovary. The uterus and right side adnexa were normal. The postoperative phase was uneventful.

The histopathology report of the tumour was showing a biphasic pattern. The stroma composed of oval to spindle atypical cells alternating with atypical tubules lined by mesothelial cells. These tumour cells have round to oval nuclei and vesicular chromatin. Mitotic figures were evident. Area of haemorrrhage with moderate amount of chronic inflammatory cell infiltrates present. The picture was suggestive of malignant mesothelioma.


  Discussion Top


Due to rarity of malignant peritoneal mesothelioma, there are only few prospective trials. The first case of peritoneal mesothelioma was reported by Miller and Wynn in a 32 year old male[5]. Pleural mesothelioma is common however isolated mesothelioma of peritoneum is rare. Besides asbestos exposure studies had reported other factors such as Simian virus-40 infection, exposure to erionite, vaccine products, genetic susceptibility, abdominal radiotherapy and chronic peritonitis in its pathogenesis[6],[7],[8]. As the patients with mesotheliomas do not present with specific symptoms this causes difficulty and delay in the diagnosis and treatment. Patients with mesotheliomas generally present with either abdominal pain or abdominal distention and ascites without pain[9].

Imaging techniques such as ultrasonography and CT scan are useful diagnostic tools. Based on the CT scan findings there are two types of mesothelioma, the ‘dry’ type is associated with multiple small masses or a single dominant localized mass on imaging with little or no ascites. In the ‘wet’ type, CT reveals widespread small nodules with ascites but no dominant mass[10].

However diagnosis is confirmed only on pathological examination of the tissue. MPM is divided into three histologic subtypes: epithelioid, sarcomatoid, and biphasic/mixed. The epithelioid subtype which is most common and having better prognosis is composed of cells that resemble normal mesothelial cells in a tubulopapillary or trabecular pattern with uncommon mitotic figures. The sarcomatoid subtype is composed of tightly packed spindle cells with the occasional presence of malignant osteoid, chondroid or muscular elements. The biphasic subtype is defined as containing both epithelioid and sarcomatoid components, with each contributing at least 10% of the overall histology[11]. Both sarcomatoid and biphasic types have poorer prognosis.

In recent years, multi’modality treatment has become the treatment of choice. It includes cytoreducti’ve surgery along with either intraperitoneal chemotherapy or radiotherapy[12]. The treatment with cytoreducti’ve surgery and heated intraperitoneal chemotherapy (CRS-HIPEC) has resulted in a median survival of 50-60 months[13]. Research is going on to identify molecular pathways in MPM, including EGFR, mesothelin, and vascular endothelial growth factor (VEGF) pathways.

Studies have identified that favourable prognosis is associated with young age, histopathology , lack of minimal residual disease after tumour resection, absence of lymph node involvememt and female sex[12].

Although studies have not shown any biological markers to be of prognostic value. Robinson et al. identified a soluble mesothelin-related protein (SMRP) present in the serum as a marker of malignant mesothelioma with a sensitivity rate of 83% and specificity rate of 95%. Changes in serum SMRP levels are thought to parallel the clinical course and mesothelioma tumour size[14].


  Conclusion Top


Due to its rarity and atypical presentation the disease is usually diagnosed at advanced stage. Peritoneal mesothelioma is an uncommon disease, but should be considered in patients presenting with abdominal mass, abdominal pain, and ascites, especially in whom the initial diagnosis is not clear. Advancement in treatment is going on with CRS-HIPEC being used as first line therapy.



 
  References Top

1.
L. Tenaglia, L. Proiett, S. Calì, S. Trovato, N. Accurso, C. DI Stefano et al Peritoneal malignant mesothelioma: case report. G Chir 2007;Vol. 28 (11/12): 435-438.  Back to cited text no. 1
    
2.
Kim J, Bhagwandin S, Labow DM. Malignant peritoneal mesothelioma: a review. Ann of Transl Med2017 Jun; 5(11): 236.  Back to cited text no. 2
    
3.
Boffetta P. Epidemiology of peritoneal mesothelioma: a review. Ann Oncol 2007;18:985- 90.  Back to cited text no. 3
    
4.
Munkholm-Larsen S, Cao CQ, Yan TD. Malignant peritoneal mesothelioma. World J Gastrointest Surg. 2009;1(1):38-48.  Back to cited text no. 4
    
5.
Miller J, Wynn H. Malignant tumor arising from endothelium of peritoneum, and producing mucoid ascitic fluid. J Pathol Bacteriol 1908;12:267-78.  Back to cited text no. 5
    
6.
Bocchetta M, Di Resta I, Powers A, Fresco R, Tosolini A, et al. (2000) Human mesothelial cells are unusually susceptible to simian virus 40-mediated transformation and asbestos cocarcinogenicity. Proc Natl Acad Sci U S A 97: 10214-10219.  Back to cited text no. 6
    
7.
Gilks B, Hegedus C, Freeman H, Fratkin L, Churg A (1988) Malignant peritoneal mesothelioma after remote abdominal radiation. Cancer 61: 2019-2021.  Back to cited text no. 7
    
8.
Peterson JT Jr, Greenberg SD, Buffler PA (1984) Non-asbestos-related malignant mesothelioma. A review. Cancer 54: 951-960.  Back to cited text no. 8
    
9.
P.H.Sugarbaker, Y. I. Z. Acherman, S. Gonzalez-Moreno et al., “Diagnosis and treatment of peritoneal mesothelioma: the Washington Cancer Institute experience,” Seminars in Oncology, vol. 29, no. 1, pp. 51-61, 2002.  Back to cited text no. 9
    
10.
Available from :< www.mesotheliomaweb.org/peritoneal.htm>.  Back to cited text no. 10
    
11.
Levy AD, Arnaiz J, Shaw JC, et al. From the archives of the AFIP: primary peritoneal tumors: imaging features with pathologic correlation. Radiographics 2008;28:583-607.  Back to cited text no. 11
    
12.
A. Feldman, S. Libutt, J. Pingpank, et al. Analysis of factors associated with outcome in patients with malignant peritoneal mesothelioma undergoing surgical debulking and intraperitoneal chemotherapy. Journal of Clinical Oncology2003; 21 (24):4560-4567.  Back to cited text no. 12
    
13.
D.H. Sterman. Advances in management of mesothelioma, Respirology 2005; 10: 266-283.  Back to cited text no. 13
    
14.
B.W. Robinson, J. Creaney, R. Lake, et al. Soluble mesothelin-related protein-a blood test for mesothelioma.Lung Cancer2005; 49 (1): S109-S111.  Back to cited text no. 14
    




 

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