Malignant Peritoneal Mesothelioma a Case Report

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					Acta Chir Belg, 2009, 109, 408-410

Malignant Peritoneal Mesothelioma : a Case Report
M. Vuković*, D. Krivokuća**, N. Moljević*
*Clinical Centre of Vojvodina, Clinic for Abdominal, Endocrine and Transplantation Surgery, Novi Sad, Republic of
Serbia ; **Department of Anatomy, Faculty of Medicine, Novi Sad, Republic of Serbia.

Key words. Peritoneum ; mesothelioma.

Abstract. In this paper we report a case of malignant peritoneal mesothelioma, a rare abdominal tumour. A 72-year-old
male with a medical history of heart disease presented to our Clinic because of pain in the right half of the abdomen.
Diagnostic procedures, including clinical and laboratory examination, X-ray, ultrasonography and computed
tomography, revealed a tumour in the right lower quadrant of the abdomen. The approximate size of the tumour size at
initial detection was 7 cm. During the pre-operative procedure an evident growth of the tumour was noticed, indicating
exploratory laparotomy. Intra-operative findings revealed a large tumour of the anterolateral abdominal wall, involving
the greater omentum. Tumour resection was performed, as well as resection of the portion of the anterolateral abdomi-
nal wall and omentectomy. Postoperative immunohistochemical analysis revealed malignant peritoneal mesothelioma.

Introduction                                                   ma occurs more often in men than in women, who are
                                                               less exposed to asbestos.
Malignant peritoneal mesothelioma is a rare abdominal             Mesothelioma is mostly diagnosed between the ages
tumour, which is in many cases not diagnosed until after       of 50 and 70, and the period from the onset of first symp-
surgical exploration. Development of such tumours is not       toms to final diagnosis is usually 4-6 months. The most
gender-, age-, ethnically-, geographically or genetically-     common symptoms in patients with peritoneal mesothe-
dependent (1).                                                 lioma include abdominal pain (60%), anorexia (27%),
   Mesothelioma is a malignant neoplasm arising from           fatigue (12%) and nausea (11%). The usual clinical pre-
the pleura (65-70%), peritoneum (30%) or may even              sentations of the peritoneal mesothelioma are abdominal
arise rarely in the tunica vaginalis of the testis and peri-   distention (56%), ascites (37%), weight loss (38%) and
cardium (1-2%). A long history of asbestos exposure has        abdominal tumour (11%) (4).
been implicated in the pathogenesis of 50% of cases of            This paper presents a case of malignant peritoneal
malignant peritoneal mesothelioma. The correlation of          mesothelioma diagnosed after explorative laparotomy
asbestos exposure with peritoneal mesothelioma is less         and immunohistochemical analysis.
strong than with pleural mesothelioma. The association
of malignant peritoneal mesothelioma with Simian virus
                                                               Case report
40 (SV40) is still conflicting (2). The influence of
genetic factors on the development of the disease is still
to be elucidated (3). The period of clinical latency from      A 72-year-old male who presented with pain localised in
the initial exposure to asbestos until the development of      the right half of the abdomen was examined in January
mesothelioma may extend over 15-50 years. There are            2006. Clinical examination revealed a palpable tumour in
three common types of malignant mesothelioma : the             the lower right quadrant of the abdomen. The tumour
epithelioid, the sarcomatoid and the non-sarcomatoid.          was oval, about 7 cm in size, and was fixed to the antero-
The best survival rate was observed in the patient             lateral abdominal wall.
population with epithelioid mesothelioma (55-65%).                Results of laboratory examination were within the
Pathohistological findings strongly resemble adeno-            range of reference values. Ultrasonography and colono-
carcinoma. The sarcomatoid type (10-15%) is similar to         graphy examinations did not identify the site of tumour
sarcomas. The non-sarcomatoid type (20-35%) reveals            origin. Computed tomography did not identify the pri-
elements of the epithelioid and sarcomatoid forms (1).         mary site of the tumour, yet demonstrated its peritoneal
   The average prevalence in the USA is one to two cases       dissemination. There were no significant increases in
per million per year, with an anticipated incidence of         values for tumour markers Carcino-embryonic antigen
200-400 newly diagnosed cases per year (2). Mesothelio-        (CEA) and Cancer antigen 19-9 (Ca19-9).
Malignant Peritoneal Mesothelioma                                                                                    409

                                                                   Malignant mesothelioma mostly develops over a long
                                                               period of exposure to asbestos. The highest incidence of
                                                               the disease in North America is expected in 2010, where-
                                                               as more then 250,000 lethal outcomes are predicted in
                                                               Europe in the coming 20 years (2).
                                                                   Specific tests for proving this type of malignancy are
                                                               still lacking. In our case, the definitive diagnosis was
                                                               made on the basis of explorative laparotomy, which cor-
                                                               responds with the experiences of other authors (6-8).
                                                               Considering that our patient spent his life working as a
                                                               construction worker in Germany, there is reasonable sus-
                                                               picion that he has been exposed to asbestos over a long
                                                               period of time.
                           Fig. 1
                                                                   Malignant mesothelioma is a rare disease identified in
         Resected greater omentum with the tumour              only 0.01-0.1% of all autopsy findings (6-8). Peritoneal
                                                               mesothelioma accounts for only 20-30% of all cases of
                                                               malignant mesothelioma (7-9). Ascites, associated with
                                                               malignant mesothelioma, results in abdominal disten-
                                                               sion, and is identified in 90% of patients (8, 9). Some
   During the diagnostic procedure and pre-operative           authors suggest biopsy as the method of choice in diag-
treatment, evident tumour growth was observed. The             nosing malignant mesothelioma (6, 9). The best marker
tumour reached a size 20 10 cm, spreading from the             for differentiating malignant mesothelioma from malig-
anterior superior iliac spine towards the epigastrium. The     nant abdominal tumours is the fact that malignant
time to diagnosis was 2 months because of actual cardi-        mesothelioma is immunohistochemically positive for
ologic problems (absolute arythmia, cardiomyophatia,           calretinin, whilst negative for CEA (6).
hypertension) and transition from oral to parenteral anti-         The prognosis for malignant mesothelioma is deter-
coagulant therapy. Intra-operative examination identified      mined by numerous factors, i.e. the size and stadium of
peritoneal dissemination, particularly in a Douglas’           the tumour, its spread and cellular type, as well as by
pouch. The greater omentum was adhered to the antero-          patient’s response to the applied therapy. The most
lateral abdominal wall on the right side, proceeding with-     important clinical factors are the completeness of cytore-
out infiltration along the right colon, callous, with dilat-   duction and the nuclear size (10). The treatment of
ed veins, and with a great number of swollen lymph             malignant peritoneal mesothelioma generally implicates
glands. The surgical procedure included omenectomy             surgical treatment, chemotherapy and radiological thera-
and resection of the tumour and rectus muscle of the           py or, in most cases, the combination thereof. Common
abdominal wall, as far as the macroscopically healthy tis-     therapy techniques for this kind of mesothelioma include
sue (Fig. 1).                                                  extensive cytoreduction and hyperthermic intraperitoneal
   Standard histological examination suggested adeno-          chemotherapy (HIPEC) (11). In our case, due to the
carcinoma ; however, this diagnosis did not conform            advanced spread of the tumour, the advanced age of the
with the macroscopic intra-operative findings.                 patient and his poor general condition, no adjuvant
Secondary immunohistochemical analysis (calretinin,            chemotherapy was applied. The patient underwent post-
vimentin and epithelial membrane antigen (EMA)                 operative multiple palliative paracentesis of the ascites
staining) was performed, revealing the diagnosis : malig-      and finally died 4 months after the diagnosis. In cases of
nant epitheloid mesothelioma. During the postoperative         diffuse spreading of the malignant mesothelioma,
period the patient was not subjected to chemotherapy and       chemotherapy is preferable to surgical treatment (6).
died four months after surgery.                                There are reports on complete remission after cisplatin
                                                               (cis-diamminedichloroplatinum) chemotherapy (6, 8).
Discussion                                                     After surgical removal of the tumour and peri-operative
                                                               intraperitoneal chemotherapy, female patients with
The peritoneum is a two-layered serous membrane com-           diffuse malignant peritoneal mesothelioma revealed
posed of mesothelial cells, with a dense vascular and          better survival rates than men (12). The efficacy of radio-
lymph capillary network. Peritoneal mesothelioma is a          therapy in the treatment of malignant peritoneal
primary tumour of the peritoneal mesothelium. The              mesothelioma has not yet been confirmed (6).
tumour is classified as benign, malignant or borderline            In Serbia there is no reliable database of malignant
malignant. The benign cystic peritoneal mesothelioma is        diseases, which is the primary prerequisite for monitor-
extremely rare, and occurs mostly in female patients (5).      ing the incidence, designing the appropriate treatment
410                                                                                                                   M. Vuković et al.

and assessing the quality and outcome of the therapy.                   7. STOUT A. P. Solitary fibrous mesothelioma of the peritoneum.
                                                                           Cancer, 1950, 3 : 820-6.
Diagnostic problems associated with malignant peri-                     8. NAKA H., NAKA A. Clinicopathological study of 100 Japanese
toneal mesothelioma at our clinic are similar to those at                  patients with peritoneal mesothelioma in Japan. Gan No Rinsho,
clinics worldwide and definitive diagnosis can only be                     1984, 30 : 1-10 (in Japanese).
                                                                        9. MOERTEL C. G. Peritoneal mesothelioma. Gastro-enterology, 1972,
made after surgical exploration and immunohistochemi-                      63 : 346-50.
cal analysis.                                                          10. YAN T. D., BRUN E. A., CERRUTO C. A., HAVERIC N., CHANG D.,
                                                                           SUGARBAKER P. H. Prognostic indicators for patients undergoing
                                                                           cytoreductive surgery and peri-operative intraperitoneal chemo-
                                                                           therapy for diffuse malignant peritoneal mesothelioma. Ann Surg
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