Aggressive multiple myeloma presenting as mesenteric panniculitis

A review of 17 cases of mesenteric panniculitis in Zhengzhou Ninth People's Hospital in China

PURPOSE

Mesenteric panniculitis (MP) represents the uncommon, benign and chronic inflammatory disorder affecting the mesenteric adipose tissues. Its etiology, diagnosis and treatment remain unnoticed. Our report focused on shedding more lights on this condition.

PATIENTS AND METHODS

Seventeen MP patients were identified by searching the electronic medical record system in the Zhengzhou Ninth People's Hospital using the search terms "Mesenteric panniculitis" from October 2015 to March 2023. All cases were diagnosed with MP through computed tomography (CT). Their clinical features and treatments were analyzed.

RESULTS

There were altogether 17 cases enrolled for this analysis. The male to female ratio was 8:9, and the median age at diagnosis was 64 (range: 37-96) years. There were 15 patients (88.2%) showing abdominal pain to varying degrees. The proportions of symptoms of nausea, vomiting and fever were 23.5%, 23.5% and 41.2%, respectively. Neoplastic disease was present in 3 patients (17.6%). Meanwhile, 9 patients (52.9%) had gallstones, 3 (17.6%) had cholecystitis and 1 (5.9%) had gallbladder polyps. Six patients (35.3%) received antibiotics treatment only and 1 (5.9%) received oral antibiotics and prednisone. One patient (5.9%) received antibiotics followed by prednisone treatment, because the symptoms were significantly relieved after antibiotic treatment, while the disease recurred soon after, and the symptoms improved again after prednisone treatment. The abdominal pain in 9 patients (52.9%) was relieved spontaneously. Two patients (11.8%) died, including one due to respiratory failure caused by pneumonia and the other one because of pancreatic cancer with lung and liver metastases.

CONCLUSION

MP is a poorly understood chronic inflammatory disease. Patients often have abdominal pain as the main symptom, accompanied by comorbidities in the gallbladder, and the prognosis is usually good after correct diagnosis and treatment, Therefore, the present report aims to promote the awareness among clinicians of patients with non-classic abdominal symptoms, so as to avoid misdiagnosis or missed diagnosis.

Concurrent Liver and Mesentery Primary Extraosseous Multiple Myeloma on 18F-FDG PET/CT

ABSTRACT

Extramedullary multiple myeloma (EMM) is a subset of multiple myeloma with a poor prognosis. We report a rare case with biopsy-proven concurrent liver and mesentery primary EMM at the time of initial staging after serologic diagnosis of multiple myeloma. 18F-FDG PET/CT is valuable in detection of EMM when the patient has no osseous lesions and a negative bone marrow biopsy.

Sclerosing Mesenteritis

Sclerosing mesenteritis is a rare non-neoplastic disorder characterized by fat necrosis, chronic inflammation, and fibrosis typically of the small bowel mesentery. Our understanding of this disorder is limited by its rarity as well as inconsistent terminology used across the literature. While prior abdominal surgery or trauma, autoimmunity, infection, ischemia, and malignancy have been suggested to be involved in the pathogenesis of the disorder, it remains poorly understood. The clinical course of sclerosing mesenteritis is generally benign with a large proportion of patients diagnosed incidentally on imaging obtained for other indications. In a subset of patients, symptoms may arise from a mass effect on the bowel, lymphatics, or vasculature resulting in bowel obstruction, chylous ascites, or mesenteric ischemia. Symptomatic patients should be treated with a combination of corticosteroid and tamoxifen as first-line therapy based on retrospective case series and experience in other fibrosing disorders. Surgical intervention may be required in those with persistent obstruction despite conservative treatment, though complete resection of the mass is often not feasible given intimate involvement with the mesenteric vasculature. A careful use of terminology and communication between the radiologist, pathologist, and clinicians in the care of these patients will be essential to future efforts at understanding this disease.

Mesenteric panniculitis: still an ambiguous condition

PURPOSE

To study the possible relationship between mesenteric panniculitis (MP) visible on computed tomography (CT) and the presence of an underlying neoplastic disease.

PATIENTS AND METHODS

A retrospective analysis of 158 patients with CT examinations that revealed the presence of MP was performed. CT images were analyzed by two different radiologists using morphological criteria validated in the radiological literature. The presence, frequency and type of neoplastic lesions associated with MP were assessed.

RESULTS

MP was asymptomatic in 96/158 patients (61%). Fat halo sign and pseudocapsule were visible on CT in 89/158 (56%) and 93/158 (59%) patients, respectively. Underlying neoplastic disease was present in 88/158 patients (56%). The neoplastic diseases most often associated with MP were lymphoma (28%), melanoma (18%), colorectal cancer (15%) and prostate cancer (13%).

CONCLUSION

MP has typical CT appearance and is associated with underlying neoplastic disease in 56% of patients. Such levels of association might suggest that MP may be considered as a paraneoplastic condition. Hence, incidental depiction of MP on CT in a patient without known neoplastic disease should incite radiologists to further scrutinize CT examination for presence of synchronous neoplastic lesions.

Mesenteric panniculitis: an update

In 1924, mesenteric panniculitis was first described in the medical literature by Jura et al. as 'retractile mesenteritis.' It represents a spectrum of disease processes characterized by degeneration, inflammation and scarring of the adipose tissue of the mesentery. The clinical presentations vary according to the stage of the disease and they include abdominal pain, weight loss, nausea and vomiting. Computed tomography findings are usually diagnostic. The gross findings include thickening of the mesentery, mass lesions and adhesion to the surrounding organs. Histologically, there is a chronic inflammatory process involving the adipose tissue with fat necrosis, inflammation and fibrosis. Herein, the authors address the clinicopathological features, course, treatment and pathogenetic mechanisms of mesenteric panniculitis.

Refractory sclerosing mesenteritis involving the small intestinal mesentery: a case report and literature review

A 28-year-old Japanese man presented with upper abdominal pain. Computed tomography (CT) revealed a soft tissue mass in the small bowel mesentery. We diagnosed the patient with sclerosing mesenteritis according to the histological findings of small bowel mesentery. Although he was treated with prednisolone, colchicine and azathioprine, neither his symptoms nor CT findings improved. This case is rare in that the disease was refractory. The characteristics of Japanese patients with sclerosing mesenteritis involving small bowel mesentery are not well understood. We herein describe the details of such patients based on a literature review including 32 recently reported Japanese cases.

Relationship between mesenteric abnormalities on computed tomography and malignancy: clinical findings and outcomes of 359 patients

BACKGROUND

Mesenteric abnormalities are detected on abdominal computed tomography (CT) performed for various indications.

GOALS

Determine the risk of malignancy on follow-up of patients with these abnormalities without a preexisting malignancy.

STUDY

Data were collected on all patients at NorthShore University HealthSystem with abdominal CT scan reports of mesenteric abnormalities labeled as "panniculitis" from January 2005 to April 2010.

RESULTS

Three hundred fifty-nine patients were identified, 81 (22.6%) had a known malignancy at the time of the index abdominal CT scan. Nineteen (6.8%) of the 278 had a new diagnosis of malignancy on evaluation of the findings of the index CT scan. Among the 240 (86.33%) that did not have a notation of the abnormality in their medical record, 11 (4.58%) developed a malignancy during the study period. Sixty-eight of the 248 (24.46%) without a known malignancy had diseases associated with mesenteric abnormalities. The presence of these were associated with a reduction in the likelihood that the abnormalities are associated with new or delayed diagnosis of a malignancy (odds ratio, 0.197; 95% confidence interval, 0.0045-0.8501; P=0.013). Progression of underlying malignancy was unlikely in those where the mesenteric abnormalities did not worsen in appearance on follow-up CT scans (odds ratio, 0.03268; 95% confidence interval, 0.0028-0.3761; P=0.0061).

CONCLUSIONS

In the presence of an underlying disease associated with these findings, the subsequent finding of a malignancy is less likely. In addition, neglect of these findings may result in delayed diagnosis of cancer.

Spontaneous resolution of severe, symptomatic mesocolic panniculitis: a case report

Background

Mesenteric panniculitis is a rare chronic fibrosing inflammatory disease that typically affects the adipose tissue and mesentery of the small intestine but may also affect the mesosigmoid and the mesocolon. The pathology of this disease remains unclear despite association with some malignancies or inflammatory disorders. We report a case of mesocolic panniculitis and a literature review of its clinical presentation, imaging findings, associated conditions and treatment options.

Case presentation

A 64 year-old Caucasian man was admitted to the gastroenterology department for severe weakness, left lower quadrant abdominal pain, weight loss and diarrhoea. Physical examination revealed a palpable firm mass occupying the entire left part of the abdomen. Abdominal CT-scan showed fatty infiltration of the mesosigmoid and left mesocolic fat which was strongly suggestive of panniculitis. Laparoscopic surgery revealed an inflamed and edematous mesocolon and mesosigmoid; the sigmoid mucosa appeared petechial which was suggestive of venous ischemia. Histological examination of surgical biopsies revealed mesocolic panniculitis. Despite exhaustive investigation, no associated conditions were found and the cause was classified as idiopathic. Surprisingly, the patient clinically improved without therapeutic intervention other than supportive care.

Conclusion

Although mesenteric panniculitis is most often a radiographic diagnosis without clinical symptomatology, it can also present with significant general status alteration. We report a case of mesocolic panniculitis complicated by development of an inflammatory mass associated with ischemic colitis. Mesenteric panniculitis is a difficult diagnosis to make which typically requires histologic confirmation. The overall prognosis is good with supportive treatment.

[Mesenteric panniculitis]

Mesenteric panniculitis is a nonspecific inflammatory process affecting the fatty tissue at the root of the mesentery. This term is also used to describe the clinical and imaging findings in this disorder. Mesenteric panniculitis can be a misleading term: it is commonly misused to design an increased density of the mesentery without prejudice regarding the etiology. Pain is the main clinical symptom. Half of the patients are asymptomatic. There is a palpable mass in half of cases. Laboratory tests sometimes reveal an acute phase reaction of varying intensity. Mesenteric panniculitis is suspected when CT scan shows increased density of the mesenteric fat. Nevertheless, only histological examination could establish the diagnosis. Histologic examination may reveal various stages: lipodystrophy (the first stage when fat necrosis is predominant), mesenteric panniculitis (a majority of infiltrating lymphocytes), sclerosing mesenteritis (the end stage when fibrosis is predominant). Histopathologic differential diagnoses are lymphomas, lipomas, liposarcomas that can mimic mesenteric panniculitis on CT scan. Mesenteric panniculitis is associated with various diseases, especially with intra-abdominal inflammatory process. It also can be idiopathic. Rare complications can occur with vascular or digestive tract compressions. Empirical treatment is only useful in symptomatic patients. Colchicine, corticosteroids or immunosuppressive agents can be used. The only interest of surgery is the histological confirmation of the diagnosis. A better understanding of the pathophysiology of the immunoregulatory functions of adipose tissue will improve mesenteric panniculitis management.

Sclerosing Mesenteritis: Diverse clinical presentations and dissimilar treatment options. A case series and review of the literature

Sclerosing mesenteritis (SM) is a rare pathological condition affecting the mesentery. It is a benign, non-specific inflammation of the adipose tissue of the mesentery of the small intestine and colon. It is characterized by a variable amount of chronic fibrosis. Its etiology is unknown, the pathogenesis is obscure, while the pathological characteristics of the disease are unspecific. The initial clinical presentation varies from typically asymptomatic to that of an acute abdomen. The diagnosis is suggested by computed tomography but is usually confirmed by surgical biopsies. Treatment is largely empirical; it is decided upon on the basis of the clinical condition of the patient, and usually a few specific drugs are used. Surgical resection is sometimes attempted for definitive therapy, although the surgical approach is often limited. We will present five cases of SM as well as a review of the available literature in order to state and compare a variety of clinical presentations, diverse possible etiologies and dissimilar treatment options.

An Interesting Case of Recurrent Small Bowel Obstruction

Sclerosing mesenteritis is associated with a spectrum of diseases which include mesenteric lipodystrophy and mesenteric panniculitis. This inflammatory and fibrosing disorder can affect the small and large bowel wall and mesenteric vessels by exerting a mass effect. The following case highlights the difficulties with diagnosing and managing this unusual disease. A 64-year-old man presented with acute central abdominal pain, radiating to his back, and profuse vomiting. He was diagnosed clinically with small bowel obstruction. He had had an episode of small bowel obstruction 6 years earlier. At this time, he underwent an exploratory laparotomy, and a mass was identified in the small bowel mesentery. The features were thought to be in keeping with sclerosing mesenteritis. He had a dramatically favourable response to the initiation of prednisolone. He continued to be well and asymptomatic for a further 5 years on long-term maintenance low-dose steroids and 6-mercaptopurine. He re-presented in 2009 (six years after initial presentation) with very severe acute abdominal pain and vomiting. He had no recent change in weight or appetite, and had not had time off work. He underwent a second laparotomy and the tissue diagnosis was of metastatic carcinoid tumour involving the small bowel mesentery. This is the first case to our knowledge where sclerosing mesenteritis has been confirmed histologically on biopsy and then subsequently diagnosed with histologically proven carcinoid tumour. For this particular reason it must be always remembered that sclerosing mesenteritis is a 'pathological' and not a radiological diagnosis and that a large proportion of cases are associated with neoplasia.

Sclerosing mesenteritis affecting the small and the large intestine in a male patient with non-Hodgkin lymphoma: a case presentation and review of the literature

Introduction

Sclerosing mesenteritis is a rare disease resembling a mesenteric tumour. We present here a case of sclerosing mesenteritis that affected both the large and the small intestine of the patient. Therapeutic and diagnostic issues are discussed.

Case presentation

A 62-year-old man with a history of non-Hodgkin lymphoma presented with fatigue, a palpable tender abdominal mass and clinical signs of progressing intestinal obstruction. The preoperative evaluation failed to prove recurrence of the lymphoma or any other definite diagnosis. A laparotomy was performed through a midline incision. The mesentery resembled a tumour-like thickened and fibrotic mass. Abundant, rigid intestinal loop adhesions were observed. Diffuse fibrotic infiltration of the ileum and of the sigmoid colon, which obviously affected the intestinal vascular supply, were identified. A right colectomy and partial sigmoidectomy were performed. Pathological evaluation revealed extensive myofibroblastic reaction of the mesentery with accompanying loci of fat necrosis and areas of inflammation. A diffuse fibrotic infiltration that focally showed a ground-glass appearance was observed. The post-operative course was complicated by respiratory insufficiency and infections and the patient died 2 months after the operation.

Conclusion

Sclerosing mesenteritis that affects both the small and the large intestine is extremely rare. The disease is characterized by myofibroblastic reaction, fat necrosis and diffuse fibrosis of the mesentery. Pathological confirmation may be required for definite diagnosis. If the disease is characterized by severe and diffuse fibrosis, then the application of surgical therapy may be problematic.

Sclerosing mesenteritis as a rare cause of abdominal pain and intraabdominal mass: a cases report and review of the literature

Sclerosing mesenteritis is a rare, benign, and chronic fibrosing inflammation disease with unknown etiology that affects the mesentery of small bowel and colon. The disease has two well-established histological types: the acute or subacute form known as mesenteric panniculitis and the chronic form known as retractile or sclerosing mesenteritis. Because the sclerosing mesenteritis is lack of special clinical manifestation and typical signs, so the patients are very easy to be misdiagnosed. The correct diagnosis of sclerosing mesenteritis depends on pathological examination and exploratory laparotomy. We report a case of sclerosing mesenteritis in a 52-year-old male who presented with chronic abdominal pain and intraabdominal mass. This patient had a long-term and heavy drinking history. He was misdiagnosed as celiac teratoma by CT examination and then underwent an exploratory laparotomy at March 2 2004. A mass, its diameter being about 5 cm, was detected in mesentery of distal ileum. Although a few small intestines tightly adhered on the mass, the involved intestine had no obstruction. The intraoperative biopsy indicated that it was an inflammatory mass. The mass and adhered intestines were removed. He was diagnosed with sclerosing mesenteritis by histopathological examination of paraffin section. After operation, this patient went well and lives without recrudescence at the time we wrote this paper.

The CT appearances of sclerosing mesenteritis and associated diseases

Sclerosing mesenteritis is characterized by non-specific inflammation of the mesenteric fat associated with variable amount of fibrosis. The aetiology is unclear; the pathogenesis is obscure, and even its nomenclature remains variable. It is a rare condition with imaging features that can be mistaken either for a mesenteric neoplasm or for a wide variety of non-neoplastic inflammatory conditions. Knowledge of the imaging features of this condition may prevent unwarranted aggressive therapy. This review discusses the pathogenesis, clinical manifestations of this condition, as well as illustrating the characteristic computed tomography (CT) features of sclerosing mesenteritis. A rational approach to the differential diagnosis is discussed.

[Mesenteric panniculitis]

Mesenteric panniculitis also named retractile mesenterite is a rare tumor-like lesion that thickens and shortens the mesentery. It is characterized by the association of inflammation, necrosis or fibrosis involving the adipose tissue of the bowel mesentery. The pathophysiology of this disease remains unclear despite associations with inflammatory diseases or malignancies, especially lymphomas that have been described. When symptomatic, patients may present with abdominal pain, palpable abdominal mass or intestinal obstruction. The disease remains asymptomatic in 30 to 50% of cases. Abdominal CT plays an important role in suggesting the diagnosis and can be useful in distinguishing the several conditions that can mimic mesenteric panniculitis. Nevertheless, pathologic examination of surgical excisional biopsies or sometimes percutaneous biopsies remains necessary to confirm the diagnosis and exclude an underlying infection or malignancy. Medical treatment may consist of therapy with anti inflammatory or immunosuppressive agents and can be proposed in highly symptomatic diseases. Surgical treatment should be exclusively attempted when intestinal obstruction or ischemia occur. Most of the time, it consists in intestinal derivation or segmental resection because complete excision of the lesions is often not possible. Mesenteric panniculitis usually has an uneventful clinical course and resolves spontaneously in a variable delay.

Mesenteric panniculitis: US and CT features

Mesenteric panniculitis is an aseptic inflammation of mesenteric fat. Before the age of ultrasonography (US) and computed tomography (CT), mesenteric panniculitis was rarely diagnosed, but today the disorder is more commonly encountered, often as an incidental imaging finding. Its exact cause remains unknown. This review illustrates the characteristic US and CT features of mesenteric panniculitis and discusses its differential diagnosis.