Online Second Opinion - Peritoneal Carcinosis of Undefined Nature

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        <p>second opinion - Peritoneal Carcinosis of Undefined Nature</p>
<p>This is a summary of 57 years old patient that was interested with
receiving an expert second opinion. When the patient was 2 years old he
had appendectomy, at 9 years old - intestinal invagination operation
affecting the right side and iliac fossa, with subsequent hardening of
the scar and the appearance of a sub-scar asymptomatic mass, interpreted
as a cicatricial reaction. When the patient was 38 Years old - Dupuytren
and at 50 years old - Laparoscopic Cholecystectomy.</p> <p>On December
2004 and several months later the patient suffered from intestinal sub-
occlusion ileus. A colonoscopy was performed which was negative. On
November 2005, a surgical intervention took place with the finding of an
adhesion mass in mid right abdomen. 700 cc of brown exudates was drained.
Right Hemi-Colectomy was preformed.</p> <p>The sections that were
macroscopically tested was an adhesive mass in the size of 8*10*6 cm
found that consisted of the terminal iliem and the cecum at a length of
18 cm.</p> <p>Microscopically the sections of the intestines were
diagnosed (by the Histopathological and Cytodiagnostic laboratory at the
Riunit hospital of Trieste) as Carcinoma of low grade differentiation.
Same findings were found in adipose tissue with pseudo glandular aspects.
Other parts of intestine showed the same microscpical appearance also
with papillar aspects. Markers - negative (CEA-2.10, Ca19.-2.5, Ca125-
5.4).</p> <p>On CT: small amount of fluid. Modest evidence of peritoneal
inflammation and some adhesions on abdominal wall.</p> <p>Re-examination
of the surgical material on Januarys 5th by the National Tumor Institute
suggested the diagnosis of malignant Mesothelioma monophasic of
epithelial type.</p> <p>Conclusion: Patient with Epithelia Peritoneal
Mesothelioma that experienced his first episode of intestinal sub-
occlusion on 2004.</p> <p>On the 01.10.06, the patient has undergone a
new examination at the Clinical Pharmacology and New Pharmaceuticals
Division of the European Institute of Oncology, whose anamnesis reports
an. In December 2004 a sub-occlusive episode is reported, affecting the
small intestine, which spontaneously healed. A CAT scan is performed,
with irrelevant results. During summer 2005, the abovementioned episodes
occur again and the patient undergoes a colonoscopy with irrelevant
results.</p> <p>In November 2005 he undergoes the examinations and
operation we have mentioned in the previous report.</p> <p>In light of
the information above, the specialist suggests to await the results from
new histology analyses and to repeat a thorax, abdomen and pelvis CAT
scan.</p> <p>Should the hypothesis of a mesothelioma be confirmed, it is
suggested to consult the opinion of a colleague surgeon who is expert in
peritonectomy and intraperitoneal hyperthermic treatments, as this is
considered the most efficient approach.</p> <p>In the alternative, it is
suggested to monitor the clinical trend throughout time (CAT and PET
scans after 3 months); however, only when presenting an evolving
situation or if a clear pathology is denounced via the CAT scan, the
specialist would suggest a systemic chemotherapy treatment.</p> <p>On the
other hand, should the histology be different, it is suggested to
nonetheless repeat a CAT and a PET scan in a month, and, in absence of a
clear primitiveness, it is advised to still consult the colleague
surgeons for a peritonectomy.</p> <p>The new histopathology examination
performed at the European Institute of Oncology on the 01.11.2006
reports: "Evidence compatible with a malignant epithelial mesothelioma
infiltrating the small intestine's wall. Immunophenotype of the
neoplastic population: positive as per calretinin, cytokeratin 5/6 and
WT1; negative as per CDX-2, CEA 5 and desmin."</p> <p>Another histology
examination performed at the Milan Cancer Institute on the 01.13.2006
reports: "Morphological and immunophenotypic pictures coherent with an
epithelial type of malignant mesothelioma. Immunoreactivity: Calretinin
+, CK 5/6 +, WT 180 +, CD31 -."</p> <p>The thoracic-abdominal CAT scan
with contrast performed on the 01.16.2006 reports: "In the thorax area
neither parenchymal nor pleural alterations are reported, nor mediastinal
lymphadenopathies. In the abdominal region no focal hepatic lesions are
appreciated, nor signs of dilation of the bile-duct subsequently to a
cholecystectomy. A minimal perihepatic and perisplenic liquid layer is at
all times appreciable, with a modest and homogeneous peritoneal
inspissation of the suprahepatic and suprasplenic zones; pancreas,
adrenal glands and kidneys in normal conditions (30mm cortical cyst with
greater diameter between the middle third and the lower third of the
right kidney); lymph nodal granules (with dimensions not exceeding one
centimeter) in periaortocaval area and along the iliac femoral axis.
Diffused and modest inspissation of the months, with ansae that appear
slightly conglutinated and adhering to the abdominal wall and with a
minor reduction in the transparency of the mesenterial adipose tissue, in
a situation that could also be compatible with the sequence of repeated
sub-occlusive episodes and the consequent surgical actions. In the pelvic
hole, normally extended bladder, with regular walls; no abnormal
tumefaction is evident."</p> <p>On the 01.20.2006, the patient finally
visited the surgeon he had addressed to by the medical doctor who had
examined him on the 01.10.2006, and the former procured the following
conclusion:</p> <p>"Patient with peritoneal epithelial mesothelioma that,
by interpreting the first sub-occlusive episode in 2004 as secondary to
such pathology, seems to date back to some time ago and appears with a
low degree of biological malignity. The CAT scan seems to show
diaphragmatic involvement and a significant adhesion syndrome between
ansae and abdominal wall. In order to apply a precise surgical
indication, an interview with the surgeon who operated the patient in
November 2005 seems indispensable, so as to evaluate the involvement of
the visceral peritoneum and above all of the small intestine, the latter
being a true contraindication to a surgical approach.</p> <p>The
cytoreduction via chemo-hyperthermia, followed by systemic chemotherapy
seems to be the best option (even though experimental). Should there be,
on the other hand, doubts about the surgical indication, one would opt
for systemic chemotherapy, eventually with neoadjuvant intention.</p>
<p>It is very important for the patient to know if there are other
diagnostic procedures. Assuming the histological diagnosis is Peritoneal
Mesothelioma, what is the recommended therapy and if there are
experimental protocols, including immunotherapy.</p> <p>The case was sent
to Medical Opinion ( for second opinion evaluation. The
case was sent to senior professor from Tel Aviv University to review the
case.</p> <p>The professor assumed that the diagnosis was mesothelioma
according to the various pathological reports. It is important to have
immunohistochemical staining for c-kit, EGFR, VEGFR, PDGFR-alpha for
possible targeted therapies.</p> <p>The best treatment option for
mesothelioma is radical surgery: peritonectomy + hyperthermic intra-
operative administration of chemotherapy. However, it is hard to imagine
the real intra-abdominal involvement by the tumor according to the
descriptions given by the radiologists. It is recommended to review the
CT scans and perform a PET -CT with FOG to locate all tumor sites.</p>
<p>If the tumor is inoperable, it is better to go for chemotherapy:
cisplatin + pemetrexed (Alimta), or cisplatin + gemcitabine, as a
palliative treatment or as a neo-adjuvant therapy.</p>        <!--

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