Kaohsiung Journal of Medical Sciences (2013) 29, 642e645

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CASE REPORT

Diffuse malignant peritoneal mesothelioma

Chih-An Shih a, Szu-Pei Ho b, Feng-Woei Tsay a, Kwok-Hung Lai a,Ping-I Hsu a,*

aDivision of Gastroenterology, Department of Internal Medicine, Kaohsiung VeteransGeneral Hospital and National Yang-Ming University, TaiwanbDepartment of Pathology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan

Received 28 August 2012; accepted 2 November 2012Available online 12 August 2013

KEYWORDSAsbestos;Epitheloid;Peritonealmesothelioma

* Corresponding author. Division oment of Internal Medicine, Kaohsiung386 Ta-Chung 1st Road, Kaohsiung 813

E-mail address: williamhsup@yaho

1607-551X/$36 Copyright ª 2013, Kaohttp://dx.doi.org/10.1016/j.kjms.201

Abstract Mesothelioma often originates in the pleura and less frequently in the peritoneum.This article describes a rare case of diffuse malignant peritoneal mesothelioma in a 54-year-oldmale construction worker who was admitted to our hospital with a 2-month history of progres-sive abdominal distention. Abdominal computed tomography revealed extensive peritoneal no-dularity and omental cake along with massive ascites. Imaging findings initially suggestedperitoneal carcinomatosis, primary peritoneal carcinoma, and tuberculous peritonitis. Laparo-scopic biopsy of the omentum and peritoneum confirmed the diagnosis of malignant peritonealmesothelioma of epitheloid type. Although systemic chemotherapy was administered, no tu-mor regression was found. The patient finally died of nosocomial infection.Copyright ª 2013, Kaohsiung Medical University. Published by Elsevier Taiwan LLC. All rightsreserved.

Introduction

Malignant mesothelioma is a highly aggressive primaryneoplasm of the serosal lining of the pleura, peritoneum,pericardium, or tunica vaginalis [1]. Primary diffuse ma-lignant peritoneal mesothelioma (DMPM) is a rare clinicalentity. Only 33% of those diagnosed with DMPM have ahistory of asbestos exposure [2]. This article describes a 54-year-old male patient who was admitted to our hospital

f Gastroenterology, Depart-Veterans General Hospital,62, Taiwan.o.com.tw (P.-I. Hsu).

hsiung Medical University. Publish3.05.003

with progressive abdominal distention and was diagnosedwith DMPM. The clinical and histopathological features ofthis rare lesion are described based on a review of previousliterature.

Case report

A 54-year-old male construction worker was admitted toour hospital with a 2-month history of progressive abdom-inal distention. Despite anorexia, the patient did notexperience nausea, vomiting, abdominal pain, or bodyweight loss. He also had a 25-year history of heavy alcoholconsumption. Physical examination revealed hypoactive

ed by Elsevier Taiwan LLC. All rights reserved.

Figure 2. Computed tomography scan of the abdomen showsomental cake (arrows).

Malignant peritoneal mesothelioma 643

bowel sound and abdominal shifting dullness. Paracentesisindicated exudative features with lymphocytic predomi-nance (95%) and serum-ascites-albumin gradient less than1.1 g/dL. The levels of protein, glucose, lactate dehydro-genase, and amylase were 3.3 g/dL, 39 mg/dL, 462 U/L,and 30 U/L, respectively. No malignant cells were found inascites. Additionally, ascitic fluid culture and culture foracid-fast bacilli were negative. Chest X-ray revealed noactive lung lesions such as pleural thickening and pleuraleffusion. A computed tomography (CT) scan of abdomendisclosed extensive peritoneal nodularity (Fig. 1, arrow)and omental cake (Fig. 2, arrows) along with massive as-cites. No elevation of serum CA19-9, carcinoembryonicantigen, or alpha fetoprotein level was noted. Laparoscopicbiopsy of peritoneum revealed turbid ascites and peritonealnodularity (Fig. 3, arrow). Microscopically, the specimencomprised epitheloid mesothelioma, consisting of solidnests of neoplastic epitheloid cells with slightly hyper-chromatic nuclei and small nucleoli. Tumor cells invadedthe adjacent connective tissue (Fig. 4). Malignant perito-neal mesothelioma, epitheloid type, was diagnosed byimmunohistochemistry, which exhibited positive stainingfor Wilms’ tumor 1 antigen (WT1), D2-40, calretinin, cyto-keratin, and AE1/AE3, and negative staining for muci-carmine, carcinoembryonic antigen, and MOC-31. Althoughsystemic chemotherapy was administered, no tumorregression was observed. The patient eventually died ofnosocomial infection.

Discussion

As a highly aggressive neoplasm of serosal surfaces, malig-nant mesothelioma may involve the pleura, less frequentlythe peritoneum, and, in a small percentage of cases, thetunica vaginalis, testis, or pericardium [1]. DMPM is a rare

Figure 1. Computed tomography scan of the abdomen showsmassive ascites and peritoneal nodularity (arrow).

clinical entity, accounting for approximately 30% of allmesothelioma [3]. Only 33% of DMPM patients have a historyof asbestos exposure [2]. According to a previous study,asbestos exposure is the etiology in 60% of DMPM in men and23% in women [4]. DMPM has also been associated withradiation therapy, recurrent peritonitis, mica exposure,and administration of thorium dioxide [5]. Although thepatient in this study had no definite history of asbestosexposure, as a construction worker, he had a higher likeli-hood of coming into contact with fire-retardant coatings,cement, bricks, pipes, flooring, and roofing than the gen-eral population.

The overall incidence of this disease is higher in malesthan in females, which may be due to a higher incidence ofasbestos-related occupations in men [5]. Clinically, symp-toms in these patients include the following: ascites (77%),

Figure 3. Diagnostic laparoscopy reveals turbid ascites andperitoneal nodularity (arrow).

Figure 4. Microscopic section shows the tumor is composedof epitheloid mesothelioma, consisting of solid nests ofneoplastic epitheloid cells with slightly hyperchromatic nucleiand small nucleoli. Tumor cells invade the adjacent connectivetissue (hematoxylin and eosin, 400�).

644 C.-A. Shih et al.

abdominal pain (69%), asthenia (43%), weight loss (32%),anorexia (30%), abdominal mass (30%), fever (22%), diar-rhea (17%), vomiting (15%), and inguinal or umbilical hernia(5e10%) in various associations [6]. This article describes a54-year-old man inflicted with ascites. In Taiwan, thecommon causes of ascites include liver cirrhosis, secondaryperitoneal carcinomatosis, and tuberculous peritonitis. As-cites due to DMPM is extremely rare.

Radiological assessment is typically undertaken using CTscan, although magnetic resonance imaging and positronemission tomography have been prescribed more recently[6]. DMPM may have multiple manifestations on CT,including thickening of the pleura, peritoneum, and mes-entery; nodules of various sizes and shapes; mesenteric oromental infiltrations; omental caking; ascites; bonedestruction; and lymphadenopathy [7]. According to imag-ing findings, the differential diagnosis for a typical DMPMincludes peritoneal carcinomatosis, primary peritonealcarcinoma, ovarian carcinoma in women, lymphomatosis,and tuberculous peritonitis.

Diagnosis can be made by ascitic fluid cytology, CT scan,and laparoscopy. Cytological examination of ascitic fluidremoved by paracentesis rarely results in a positive finding[8]. According to the data review of previous case reportsand the current case of DMPM [9e12], the sensitivity ofascitic fluid cytology in the diagnosis of malignant meso-thelioma was 54% (7/13). In clinical practice, ascitic fluidcytology can be used as an initial diagnostic modality formalignant mesothelioma. However, the definite diagnosisof DMPM often depends on laparoscopy or open surgery withbiopsy. The gross appearance of mesothelioma is charac-terized by soft, grayish-white, papillary nodules or massesextending over peritoneal surfaces. In pathology, malignantmesothelioma is characterized by staining for calretinin,cytokeratin 5/6, epithelial membrane antigen (EMA), WT1,antimesothelial cell antibody-1, and mesothelin withoutthe absence of staining the markers for malignancies of thegastrointestinal tract including carcinoembryonic antigen

and MOC-31 [2,13]. DMPM is categorized into three patho-logic subtypes: epithelial (56%), sarcomatous (32%), andmixed (13%) [3]. In this study, cytological examination ofascitic fluid failed to identify cancer cells. DMPM wasdiagnosed based on laparoscopic biopsy.

Previously, DMPM was treated with a combination ofsystemic chemotherapy, palliative surgery, and, in a fewpatients, total abdominal radiation capable of achieving amedian survival of 12 months [14]. Prognosis of DMPM ispoor, with a median survival rate of <1 year [6,15]. How-ever, new therapeutic strategies (e.g., combined approachwith cytoreduction surgery and hyperthermic intraperito-neal chemotherapy) have prolonged survival considerablyin selected cases in recent years [6,14].

DMPM is a rare disease characterized by a difficultdiagnosis, different presentations, variable course, andpoor prognosis. DMPM is a rare cause of ascites in Taiwan.However, it should be considered in patients inflicted withascites, particularly in those without cirrhosis, pulmonarytuberculosis, and nonperitoneal malignancy.

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