Peer Reviewed

Photoclinic

Malignant Peritoneal Mesothelioma With Refractory Ascites

Volume 59 - Issue 7 - July 2019

Authors:
Syed A. A. Rizvi, PhD, MS, MBA
Hampton University School of Pharmacy, Hampton, Virginia

Zafar Qureshi, MD
UHI CommunityCare Clinic, Miami, Florida

Mileydis Alonso, MS-IV
Nova Southeastern University, Fort Lauderdale, Florida

Dallin Walker, MS-IV
Nova Southeastern University, Fort Lauderdale, Florida

Sehrish Sikandar, MBBS
UHI CommunityCare Clinic, Miami, Florida

Javeria Waseem, MBBS
UHI CommunityCare Clinic, Miami, Florida

Citation:
Rizvi SAA, Qureshi Z, Alonso M, Walker D, Sikandar S, Waseem J. Malignant peritoneal mesothelioma with refractory ascites. Consultant. 2019;59(7):223-224.

 

A 71-year-old woman with a history of vestibular schwannoma, meningioma, asthma, ascites, and hypertension came to the clinic with concern for worsening abdominal distention, shortness of breath when walking, and swelling of her legs. She denied recent travel, recent sick contacts, chest pain, nausea, vomiting, fever, diarrhea, hematuria, dysuria, and substance abuse. She had clinical signs of recurrent ascites and was referred to the emergency department for paracentesis.

Physical examination. The patient’s vital signs were as follows: blood pressure, 130/67 mm Hg; pulse, 102 beats/min; respiratory rate, 14 breaths/min; temperature, 37°C; height 145 cm; and weight, 76.4 kg; and body mass index, 35.6 kg/m2. On general examination, abdominal distention was noted, but the patient was not in acute distress.

Neurological examination findings showed cranial nerves to be intact, although the patient was deaf in the right ear and wears a hearing aid on the left ear. Cardiac examination revealed regular heart rate and rhythm with no murmurs, rubs, or gallops. On abdominal examination, bowel sounds were present; other findings were ascites, epigastric tenderness, right and left upper quadrant tenderness, and abdominal distention. The extremities featured 2+ pitting edema.

Laboratory tests. Laboratory test results were within normal reference ranges, including the following: white blood cell count, 6900/µL; hemoglobin, 14.2 g/dL; sodium, 134 mEq/L; potassium, 4.6 mEq/L; calcium, 9.4 mg/dL; creatinine, 0.57 mg/dL; blood urea nitrogen, 8 mg/dL; and fasting glucose, 106 mg/dL.

A computed tomography (CT) scan of the abdomen with intravenous contrast showed a significant amount of ascites fluid, calcified liver nodules, induration and nodularity of the omentum, and a nodule measuring 16 × 10 mm in the anterior mid abdomen (Figure) suggestive of peritoneal carcinomatosis.

mesothelioma
Figure. Abdominal CT scan showing a nodule in the anterior mid abdomen.

An ultrasound-guided biopsy of the lower abdominal mass in the periumbilical area was performed. Pathology results confirmed malignant mesothelioma with epithelioid-type tumor cells, positive for calretinin, monoclonal antibody D2-40, cytokeratin 5/6, and Wilms tumor protein (WT1), but negative for BRCA1-associated protein 1 (BAP-1) expression. The possibility of carcinoma was further excluded by negative test results for PAX8, epithelial membrane antigen (EMA), endoplasmic reticulum (ER) marker, Ber-EP4, CD15, monoclonal carcinoembryonic antigen (CEA), B72.3, thyroid transcription factor 1 (TTF-1), and CDX2.

Discussion. Malignant pleural mesothelioma (MPM), first described in 1908, is a very rare type of cancer originating in the mesothelial surface lining cells of the peritoneum.1 The prognosis is poor, with a median survival range of 2 to 5 years after diagnosis, with incidence rates of 1.94 per 100,000 men and 0.41 per 100,000 women.2,3 Histologically, MPM is classified into 3 subtypes: epithelioid, sarcomatoid, and biphasic (mixed).4 Recently however, epithelioid MPM has been further differentiated into 2 subgroups.5

Both pleural and peritoneal mesothelioma are associated with asbestos exposure; however, peritoneal mesothelioma has a much weaker association.6 Our patient reported no history of asbestos exposure. Clinical symptoms of MPM include, abdominal distention, pain, and refractory ascites of unknown origin.7,8 Abdominal CT scan is often the first indictor of nodularity of the omentum, followed by confirmation via ultrasound- or CT-guided biopsy and histological and immunohistochemical assessments.9,10

Due to the rarity of MPM, no standard treatment protocols are available, and various options are used either alone or in combination. Current treatment strategies include cytoreductive surgery, hyperthermic intraoperative perfusion of intraperitoneal chemotherapy (HIPEC) alone or in combination with early postoperative intraperitoneal chemotherapy (EPIC), and whole abdominal radiation.11-13

References:

  1. Bridda A, Padoan I, Mencarelli R, Frego M. Peritoneal mesothelioma: a review. MedGenMed. 2007;9(2):32.
  2. Patel SC, Dowell JE. Modern management of malignant pleural mesothelioma. Lung Cancer (Auckl). 2016;7:63-7
  3. Kim J, Bhagwandin S, Labow DM. Malignant peritoneal mesothelioma: a review. Ann Transl Med. 2017;5(11):236.
  4. Husain AN, Colby T, Ordonez N, et al. Guidelines for pathologic diagnosis of malignant mesothelioma: 2012 update of the consensus statement from the International Mesothelioma Interest Group. Arch Pathol Lab Med. 2012;137:647-667.
  5. de Reyniès A, Jaurand M-C, Renier A, et al. Molecular classification of malignant pleural mesothelioma: identification of a poor prognosis subgroup linked to the epithelial-to-mesenchymal transition. Clin Cancer Res. 2014;20(5):1323-1334.
  6. Borczuk AC, Cappellini GCA, Kim HK, Hesdorffer M, Taub RN, Powell CA. Molecular profiling of malignant peritoneal mesothelioma identifies the ubiquitin-proteasome pathway as a therapeutic target in poor prognosis tumors. Oncogene. 2007;26(4):610-617.
  7. Ahmed I, Koulaouzidis A, Iqbal J, Tan WC. Malignant peritoneal mesothelioma as a rare cause of ascites: a case report. J Med Case Rep. 2008;2:121.
  8. Komaki T, Urata H, Mori K, Iwashita A, Ikeda K, Haraoka S. A rare case of biphasic malignant peritoneal mesothelioma with refractory ascites. Intern Med. 2017;56(7):861-864.
  9. Reuter K, Raptopoulos V, Reale F, et al. Diagnosis of peritoneal mesothelioma: computed tomography, sonography, and fine-needle aspiration biopsy. AJR Am J Roentgenol. 1983;140(6):1189-1194.
  10. Patel NP, Taylor CA, Levine EA, Trupiano JK, Geisinger KR. Cytomorphologic features of primary peritoneal mesothelioma in effusion, washing, and fine-needle aspiration biopsy specimens: examination of 49 cases at one institution, including post-intraperitoneal hyperthermic chemotherapy findings. Am J Clin Pathol. 2007;128(3):414-422.
  11. Alexander HR Jr, Bartlett DL, Pingpank JF, et al. Treatment factors associated with long-term survival after cytoreductive surgery and regional chemotherapy for patients with malignant peritoneal mesothelioma. Surgery. 2013;153(6):779-786.
  12. Turner KM, Varghese S, Alexander HR Jr. Surgery for peritoneal mesothelioma. Curr Treat Options Oncol. 2011;12(2):189-200.
  13. Siow SL, Mahendran HA. Malignant peritoneal mesothelioma presenting as ascites of unknown origin. Am J Med Case Rep. 2015;3(4):98-101.