Case 5
Call For A Slide Seminar Of African Cases (…And Not Only…)
06/09/2017
João Fraga, Paula Serra, Catarina Cerdeira, Ana Catarina Lai, Maria Beatriz Pimentão, Rui Almeida, Helder Moreira, BrunoFernandes, Graça Fernandes, Raquel Pina
Clinical history
Male, 39 years old
Chronic alcoholism (120g / day)
No history of chronic liver disease / portal hypertension
Symptoms: morning nausea and vomiting
201720152011
Primary Health Care
CHUC
40 years
Symptoms: matinal nausea and vomiting
2012
Abdominal ultrasound: "Moderate volumeperitoneal effusion surrounding the liver andalso in the pelvic excavation."
Upper abdominal CT: "Peritoneal effusion in the upperabdomen; subperitoneal thickening of the mesenteryroot and densification of the great epiploon "
IPORefractory ascitis of
unknown cause
Clinical history201720152011
Primary Health Care
CHUC
2012
43 years
Symptoms: abdominal pain(1 month duration)
Physical examination: bulky andpainful abdomen
Toraco-abdomino-pelvic CT:“Massive peritoneal effusion in all quadrants of the abdomen. Densification of the large omentum.
Peritoneal carcinomatosis can not be excluded. "
No analytical changes
Smear (Papanicolau 200x)
Biopsy (HE 100x)
Cell-Block (HE 100x)
Cyt
olo
gy Histo
logy
Gastroenterology - diagnostic paracentesis andperitoneal biopsy
BerEp4 100x
Calretinin 100x
EMA 100x
Caldesmon 100x
Ki-67 100x
Immunohistochemistry
Cell-block
Desmin 100x
Calretinin 100x
Ki-67 100x
BiopsyBerEp4 100x
Differential diagnosisReactive mesothelial proliferation
Mesothelioma
Metastatic disease
Follow-up
Clinical diagnosis of "Ascites of indeterminate cause"
Medicated with furosemide 40id, spironolactone 100id and alcohol cessation
Clinical history review: No exposure to asbestos
Clinical history
45 years
Symptoms: abdominalpain and distension, increscendo in the lastmonths
Abdominal ultrasound: "Massive peritoneal
effusion in all quadrants of the abdomen, free aspect"
No analytical changes
201720152011
Primary Health Care
CHUC
2012Regular evacuation paracentesis
Laparoscopy: • Thick, congestive peritoneum• Large ascitic effusion, dispersed
throughout all quadrants - aspiration of about 15L with harvest for cytologicalstudy
• Performed appendectomy + epiplon biopsy + parietal peritoneum biopsypsy
Clinical history
201720152011
Primary Health Care
CHUC
2012Regular evacuation paracentesis
Right iliac fossa Right hypochondrium
BerEp4 100x Calretinin 200x
EMA 100x
WT1 100x
Ki-67 (12%) 200x
Immunohistochemistry
Differential diagnosisReactive mesothelial proliferation
Mesothelioma
Metastatic disease
Histology
HE 40x
Epiploon Parietal peritoneum
HE 40x
Epiploon biopsy – witish, homogeneous, firm tissue Parietal peritoneum biopsy - white-pinkish, homogeneous and elastic tissue
CK 5,6 40x
BerEp4 40xCalretinin 40x EMA 40x
p53 200x Desmin 200x
Immunohistochemistry
Differential diagnosis
Reactive mesothelial proliferation
Well-differentiated papillary mesothelioma
Diffuse malignant peritoneal mesothelioma
Metastatic disease
Diagnosis
Diffuse malignant peritoneal mesothelioma, epithelioid, with tubulo-papillary pattern, involving serosa and subserosa of the ileo-cecal
appendix, mesoappendix, epiploon and peritoneum
Follow-up Patient proposed for intraperitonealchemotherapy
Diffuse malignant peritoneal mesothelioma
Main risk factor: exposure to asbestos
Previous contact history in 50% of cases
65%-70%
30%
1-2%
1-2%
Nonspecific clinical andradiological presentation
Late diagnosis
Uncertain biological behavior
Cytology of ascitic effusion Sensibility ≈ 25%
Peritoneal biopsy CT / laparoscopyGold standard
<75% → 50 - 60 years old
Morphology: Epithelioid / Sarcomatoid / Mixed(50-75%) (5-20%) (15-40%)
Rare neoplasia and difficult to diagnosis
Woman Man
Better prognosis