Mesenteric panniculitis: review of consecutive abdominal MDCT examinations with a matched-pair analysis

AGA Clinical Practice Update on Sclerosing Mesenteritis: Commentary

DESCRIPTION

The purpose of this American Gastroenterological Association Institute Clinical Practice Update is to review the available evidence for diagnosing and treating, as well as examine opportunities for future research in, sclerosing mesenteritis.

METHODS

This Clinical Practice Update expert commentary was commissioned and approved by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the Clinical Practice Updates Committee and external peer review through standard procedures of Clinical Gastroenterology and Hepatology. This expert commentary incorporates important and recently published studies in this field, and it reflects the experiences of the authors who are gastroenterologists with expertise in this topic.

Upper and Lower Endoscopic Findings in Mesenteric Panniculitis Patients: A Case-Control Study

Background: The natural history and prognosis of mesenteric panniculitis (MP) are not well-described. Despite referral for colonoscopy being common for this indication, colonoscopy findings in MP patients have not been reported. Therefore, we aimed to describe upper and lower gastrointestinal (GI) endoscopy findings in patients with mesenteric panniculitis, compared to matched controls, to investigate their clinical outcomes including incidence of malignancy and mortality. Methods: Retrospective case-control study was conducted, and included patients who were diagnosed with mesenteric panniculitis according to Coulier radiologic criteria on abdominal computerized tomography between 1/2005 and 12/2019, and followed to 12/2021. The case group was compared to a matched control group without MP on abdominal CT. Clinical data and the upper and lower endoscopies' reports were reviewed in both groups. We excluded patients who, beyond diagnosis of MP, were also diagnosed with current malignancy, significant intra-abdominal morbidity or inflammatory bowel disease. Results: The initial set of 376 patients with MP, after exclusion, included 187 patients. A total of 56.1% were male, with a mean age 60 ± 15 years. Of them, 74 (39%) patients underwent follow-up CT scans, which demonstrated, in 66 (89.2%) patients, a stable MP without any aggravation. Colonoscopy was performed in 89 MP patients, and 98/187 controls. No significant difference in the colonoscopies' findings was found between the two groups. Gastroscopy was performed in 84 MP and 79 controls. No case of gastric cancer was found. No statistically significant difference was found in the rate of gastroscopy findings. By the end of the follow-up period, malignancy was diagnosed in four patients of the MP group. None were colon cancer. The mortality rate in the MP group was 3.2%, without a significant difference compared to the controls. None were MP related. Conclusions: MP identified on abdominal CT is not associated with pathologic endoscopy findings or future diagnosis of colon cancer, and also has no impact on mortality rate. Since repeating abdominal CT did not reveal any disease progression, the necessity of follow-up imaging for MP should be carefully reconsidered.

Mesenteric Panniculitis as a Side Effect of Nivolumab in a Patient with Larnyngeal Cancer

Mesenteric panniculitis is rare, usually idiopathic, caused by inflammation of the fatty tissue of the mesentery, especially in the small intestine. The relation between cancer and mesenteric panniculitis is unclear. In some studies, mesenteric pannicullitis precedes cancer diagnosis; on the other hand, some studies suggest no correlations. Immunotherapeutics have a wide range of side effects; virtually, every system and organ in the body can be affected. Herein, we presented a rare case of mesenteric panniculitis in a patient with larnyngeal cancer as a side effect of nivolumab treatment. The patient was presented with nausea and vomiting and diagnosed with intravenous contrast-enhanced computed tomography and fully recovered with corticosteroid treatment. The case report highlights the importance of noticing rarely seen side effects of immunotherapy which can be treated easily with immunosuppressive agents.

Sclerosing Mesenteritis: A Concise Clinical Review for Clinicians

Sclerosing mesenteritis (SM), an idiopathic nonneoplastic condition affecting 0.18% to 3.14% of the population, is characterized by chronic fat necrosis, inflammation, and fibrosis most commonly of the mesentery of the small intestine. Sclerosing mesenteritis typically presents in the fifth or sixth decade of life, where patients with a history of abdominal surgery and/or autoimmune disease may be at higher risk. While many patients are asymptomatic, clinical features and complications are related to the mass effect resulting from the inflammation and fibrosis involved in the pathogenesis of SM. When present, common signs, symptoms, and complications include abdominal pain, weight loss, diarrhea, palpable abdominal mass on examination, bowel obstruction, chylous ascites, and mesenteric vessel thrombosis. Although SM was historically diagnosed predominantly by biopsy, current practice has shifted away from this to computed tomography imaging of the abdomen, given the invasive nature of biopsy. However, certain conditions, including mesenteric neoplasia (lymphoma, metastatic carcinoid tumor, desmoid tumor, mesenteric carcinomatosis), can mimic SM on imaging, and if clinical suspicion is equivocal, a biopsy may be warranted for definitive diagnosis. Asymptomatic patients do not require treatment. For patients with pronounced symptoms or complicated SM, the combination of tamoxifen 10 mg twice daily and prednisone 40 mg daily is the first-line pharmacotherapy; no randomized controlled trial of this regimen has been performed. Rarely, surgery may be necessary in cases of persistent bowel obstruction refractory to medical management. Sclerosing mesenteritis has an overall benign course in most cases, but disease progression and fatal outcomes have been reported.

Idiopathic sclerosing mesenteritis presenting with small bowel volvulus in a patient with antiphospholipid syndrome: A case report

BACKGROUND

Sclerosing mesenteritis is a rare disorder involving inflammation of the mesentery. Its etiology remains unclear, but it is believed to be associated with previous abdominal surgery, trauma, autoimmune disorders, infection, or malignancy. Clinical manifestations of sclerosing mesenteritis are varied and include chronic abdominal pain, bloating, diarrhea, weight loss, formation of an intra-abdominal mass, bowel obstruction, and chylous ascites. Here, we present a case of idiopathic sclerosing mesenteritis with small bowel volvulus in a patient with antiphospholipid syndrome.

CASE SUMMARY

A 68-year-old female presented with recurrent small bowel obstruction. Imaging and pathological findings were consistent with sclerosing mesenteritis causing mesenteric and small bowel volvulus. Computed tomography scans also revealed pulmonary embolism, and the patient was started on a high dose of corticosteroid and a therapeutic dose of anticoagulants. The patient subsequently improved clinically and was discharged. The patient was also diagnosed with antiphospholipid syndrome after a hematological workup.

CONCLUSION

Sclerosing mesenteritis is a rare condition, and patients with no clear etiology should be considered for treatment with immunosuppressive therapy.

Mesenteric panniculitis: a clinical conundrum

Mesenteric panniculitis is encountered frequently during abdominopelvic CT scanning, often as an incidental finding. The observation is problematic because an association with malignancy has been raised in the literature. This review will describe the CT appearances and examine the available evidence regarding the significance of this finding.Ultimately, the literature remains unclear regarding how these patients should be managed, if at all.

Mesenteric panniculitis is associated with cardiovascular risk-factors: A case-control study

BACKGROUND

This study evaluated the prevalence of cardiovascular risk-factors in patients with mesenteric panniculitis.

AIMS

To determine whether cardiovascular risk-factors and mesenteric panniculitis are associated.

METHODS

Retrospective, matched case-control study of patients referred to Meir Medical Center, Israel, 2014-2019, who underwent computerized tomography scan, were diagnosed mesenteric panniculitis by radiologic criteria. They were compared to two, matched case-control groups: hospitalized patients without mesenteric panniculitis and the general population based on Israeli Ministry of Health surveys. Patients with active malignancy, IBD or significant intra-abdominal morbidity were excluded.

RESULTS

Of 376 patients with mesenteric panniculitis diagnosed by computerized tomography, 187 were included. Compared to hospital patients, they had higher incidence of dyslipidemia (77.5%/56.7%), hypertension (52.4%/40.6%), obesity (body mass index>30) (60.4%/30.5%) and nonalcoholic fatty liver disease (42.2%/16.6%). Similar differences were observed compared to the general population. In multivariable logistic regression, dyslipidemia, obesity, and nonalcoholic fatty liver disease were independent predictors for mesenteric panniculitis.

CONCLUSIONS

Patients with mesenteric panniculitis have more cardiovascular risk-factors compared to a case-control group and to the general population. This suggests that mesenteric panniculitis is clinically significant and may be part of the metabolic morbidity burden. This association should be further explored.

CT features associated with underlying malignancy in patients with diagnosed mesenteric panniculitis: Mesenteric panniculitis: CT features associated with underlying malignancy

PURPOSE

The purpose of this study was to identify abdominal computed tomography (CT) features associated with underlying malignancy in patients with mesenteric panniculitis (MP).

MATERIALS AND METHODS

This single-institution retrospective longitudinal cohort study included patients with MP and a minimum 1-year abdominopelvic CT follow-up or 2-year clinical follow-up after initial abdominopelvic CT examination. Two radiologists, blinded to patients' medical records, conjointly reviewed CT-based features of MP. Electronic medical records were reviewed for newly diagnosed malignancies with the following specific details: type (lymphoproliferative disease or solid malignancy), location (possible mesenteric drainage or distant), stage, time to diagnosis. An expert panel of three radiologists and one hemato-oncologist, who were blinded to the initial CT-based MP features, assessed the probability of association between MP and malignancy based on the malignancy characteristics.

RESULTS

From 2006 to 2016, 444 patients with MP were included. There were 272 men and 172 women, with a median age of 64 years (age range: 25-89); the median overall follow-up was 36 months (IQR: 22, 60; range: 12-170). A total of 34 (8%) patients had a diagnosis of a new malignancy; 5 (1%) were considered possibly related to the MP, all being low-grade B-cell non-Hodgkin lymphomas. CT features associated with the presence of an underlying malignancy were the presence of an MP soft-tissue nodule with a short axis >10 mm (P < 0.0001) or lymphadenopathy in another abdominopelvic region (P < 0.0001). Associating these two features resulted in high diagnostic performance (sensitivity 100%; [95% CI: 57-100]; specificity 99% [95% CI: 98-100]). All related malignancies were identified.

CONCLUSION

Further workup to rule out an underlying malignancy is only necessary in the presence of an MP soft-tissue nodule >10 mm or associated abdominopelvic lymphadenopathy.

Colchicine as an Alternative First-Line Treatment of Sclerosing Mesenteritis: A Retrospective Study

BACKGROUND

Sclerosing mesenteritis is a rare condition characterized by chronic inflammation and fibrotic changes of the mesentery.

AIMS

To determine the long-term management and outcomes of patients with sclerosing mesenteritis.

METHODS

Patients with biopsy-proven sclerosing mesenteritis at the Mayo Clinic between January 2006 and December 2016 were identified. Clinical data were collected retrospectively.

RESULTS

One hundred and three patients were identified, median age 68.0 years (range 35.0-85.3). Most patients were symptomatic (87.4%) at presentation. Patients received no treatment (52.4%), medical therapy (42.7%) or surgery (4.9%) on initial diagnosis. The most common initial regimens were prednisone plus tamoxifen (41.9%), prednisone alone (23.3%), and prednisone plus colchicine (11.6%) with 55.6%, 57.2%, and 60% of patients improving, respectively, p = 0.85 for a difference in response rates. At least half of the patients responded to prednisone plus tamoxifen, prednisone plus colchicine, or prednisone alone at 6.0, 7.2, and 8.4 months, respectively. At a median follow-up of 45.6 months (95% CI 24.1-69.7), 65.4% of patients were receiving medical therapy. Of those receiving tamoxifen-based, steroid-based, or steroid-sparing regimens, 100%, 87.5%, and 77.8% had improved by their last follow-up appointment respectively, p = 0.15.

CONCLUSION

Prednisone plus colchicine has a similar efficacy to prednisone plus tamoxifen for the initial and long-term treatment of sclerosing mesenteritis. The majority of patients were initiated on medical therapy over the long term with most reporting symptomatic improvement within a year. Death from SM was rare.

Mesenteric panniculitis does not confer an increased risk for cancers: A systematic review and meta-analysis

BACKGROUND

Mesenteric panniculitis (MP) is a non-specific, localized inflammation at the mesentery of small intestines which often gets detected on computed tomography. An association with malignant neoplasms remains unclear. We performed a systematic review and meta-analysis to examine the association of malignancy with MP.

METHODS

MEDLINE, EMBASE, Web of Science, and Cochrane databases were searched for articles published from inception to 2020 that evaluated the association of malignant neoplasms with MP in comparison with control groups. Using random-effects method, a summary odds ratio (OR) estimate with 95% confidence intervals for malignant neoplasms in MP was estimated.

RESULTS

Four case-control studies reporting data on 415 MP patients against 1132 matched-controls met inclusion criteria and were analyzed. The pooled OR for finding a malignant neoplasm in patients with MP was 0.907 (95% CI: 0.688-1.196; P = .489). The heterogeneity was mild and non-significant. Also, there was no heightened risk of any specific type of malignancy with MP. Three more case-series with unmatched-control groups (MP: 282, unmatched-controls: 17,691) were included in a separate analysis where the pooled OR of finding a malignant neoplasm was 2.963 (95% CI: 1.434-6.121; P = .003). There was substantial heterogeneity in this group.

CONCLUSION

This meta-analysis of matched controlled studies proves absence of any significant association of malignant neoplasms with MP. Our study also demonstrates that the putative association of malignancy with MP is mainly driven by uncontrolled studies or case-series.

Utility of CT to Differentiate Pancreatic Parenchymal Metastasis from Pancreatic Ductal Adenocarcinoma

Simple Summary

The purpose of this retrospective study was to report the computed tomography (CT) features of pancreatic parenchymal metastasis (PPM) and identify CT features that may help discriminate between PPM and PDAC. At multivariable analysis, well-defined margins (OR, 6.64; 95% CI: 1.47–29.93; p = 0.014), maximal enhancement during arterial phase (OR, 6.15; 95% CI: 1.13–33.51; p = 0.036), no vessel involvement (OR, 7.19; 95% CI: 1.51–34.14) and no Wirsung duct dilatation (OR, 10.63; 95% CI: 2.27–49.91) were independently associated with PPM. A nomogram based on CT features identified at multivariable analysis yielded an AUC of 0.92 (95% CI: 0.85–0.98) for the diagnosis of PPM vs. PDAC.

Abstract

Purpose: To report the computed tomography (CT) features of pancreatic parenchymal metastasis (PPM) and identify CT features that may help discriminate between PPM and pancreatic ductal adenocarcinoma (PDAC). Materials and methods: Thirty-four patients (24 men, 12 women; mean age, 63.3 ± 10.2 [SD] years) with CT and histopathologically proven PPM were analyzed by two independent readers and compared to 34 patients with PDAC. Diagnosis performances of each variable for the diagnosis of PPM against PDAC were calculated. Univariable and multivariable analyses were performed. A nomogram was developed to diagnose PPM against PDAC. Results: PPM mostly presented as single (34/34; 100%), enhancing (34/34; 100%), solid (27/34; 79%) pancreatic lesion without visible associated lymph nodes (24/34; 71%) and no Wirsung duct enlargement (29/34; 85%). At multivariable analysis, well-defined margins (OR, 6.64; 95% CI: 1.47–29.93; p = 0.014), maximal enhancement during arterial phase (OR, 6.15; 95% CI: 1.13–33.51; p = 0.036), no vessel involvement (OR, 7.19; 95% CI: 1.512–34.14) and no Wirsung duct dilatation (OR, 10.63; 95% CI: 2.27–49.91) were independently associated with PPM. The nomogram yielded an AUC of 0.92 (95% CI: 0.85–0.98) for the diagnosis of PPM vs. PDAC. Conclusion: CT findings may help discriminate between PPM and PDAC.

Association between mesenteric panniculitis and non-neoplastic disorders

PURPOSE

To assess the relationship between MP and coexisting non-neoplastic disorders.

METHODS

Consecutive abdominal computed tomography (CT) scans of 4674 patients were evaluated retrospectively for CT features of MP between January 2017 and January 2018. Clinical findings of patients were analyzed. Four control patients were selected from our cohort for each MP patient such that they matched for age, gender and CT protocol. Statistical analysis was performed using a t, Mann-Whitney U, χ², or Fisher's test.

RESULTS

976 patients were excluded from the study due to the exclusion criteria and finally, 102/3698 patients were diagnosed with MP (mean age = 57.2 ± 12.5 years, 52% male). On CT, a hyperattenuated fatty mass (120/120), subcentimeter lymph nodes (117/120), congregation of mesenteric vessels (82/120) within the mass, a fat halo sign (28/120) and a pseudocapsule (88/120) were seen at the mesentery.The intra-observer agreement was almost perfect for the fatty mass and lymph nodes and moderate or substantial for other CT features (p < 0.001). The most prominent disorders were metabolic syndrome (MetS) and urogenital diseases in MP (45%, 37%, respectively) and control groups (31%, 26%, respectively). Between groups, no significant differences were found in the history of abdominal surgery, gastrointestinal and autoimmune diseases (p-value range 0.064-0.663); however, significant differences were found in the rates of vascular, urogenital diseases and MetS (p-value range 0.012-0.036).

CONCLUSION

MetS and urolithiasis were significantly more common in patients with MP than in those without MP. Therefore, there may be a clinically relevant association between these disorders. MetS may be a risk factor for MP and urolithiasis, and treatment of metabolic disorders should be undertaken to prevent these diseases.

CT, MRI and PET/CT features of abdominal manifestations of cutaneous melanoma: a review of current concepts in the era of tumor-specific therapies

Abdominal manifestations in patients with cutaneous melanoma include involvement due to metastatic spread and immune checkpoint inhibitor induced adverse events. The purpose of this review is to provide a critical overview of abdominal manifestations in patients with cutaneous melanoma and highlight the current imaging challenges in the era of tumor-specific therapies. Immune checkpoint inhibitors represent a treatment with demonstrated efficacy in the treatment of advanced cutaneous melanoma but are associated with several abdominal adverse events that must be recognized. CT has a role in the identification of colitis, enteritis and pancreatitis, whereas MRI has an important role in the diagnosis of autoimmune pancreatitis. Current evidence demonstrates that MRI should be the preferred imaging technique for the detection and characterization of hepatic and splenic metastases from cutaneous melanoma. The role of ¹⁸F-FDG-PET/CT should be further evaluated but current literature suggests an efficacy in the detection of pancreatic metastases not seen on CT and MRI.

Debilitating Manifestation of a Disease with Multiple Names: A Severe Case of Sclerosing Mesenteritis

Sclerosing mesenteritis (SM) is a rare inflammatory condition with unknown etiology that affects the mesenteric adipose tissue. We present a case of a 49-year-old male with severe abdominal pain who underwent abdominal biopsy confirming the presence of adipose inflammation and necrosis. The diagnosis of SM was made, and the patient was treated with prednisone and tamoxifen. As this condition is rare, there are no standard guidelines for management. This case aims to outline a possible treatment plan.

Clinical and radiological features of mesenteric panniculitis: a critical overview

The mesenteric panniculitis is a rare form of inflammation that mainly involves the mesenteric adipose tissue. The etiology remains unknown and the disease has been associated with various conditions such as cancer, abdominal trauma, previous surgery, autoimmune diseases and obesity. Mesenteric panniculitis can be divided into two main groups: the mesenteric panniculitis with only the inflammation and degeneration of the mesenteric fat, and the retractile panniculitis, mainly fibrotic, with retraction of the surrounding structures. From a radiological point of view, there are two main signs: the fat ring sign, which is the presence of normal fat around vessels and lymph nodes, and the pseudocapsula around the lesion. In this paper, we present the imaging and clinical features of mesenteric panniculits with particular reference to the differential diagnosis and the possible etiological associations. (www.actabiomedica.it)

The Complex Relationship between Mesenteric Panniculitis and Malignancy - A Holistic Approach is Still Needed to Understand the Diagnostic Uncertainties

Mesenteric panniculitis is an idiopathic, localized inflammation involving the adipose tissue of the small bowel mesentery. The association of mesenteric panniculitis with malignancy, predominantly lymphomas, has been widely reported in the medical literature. In this review article, we will discuss the clinical guidelines in the diagnosis and management of mesenteric panniculitis and the clinical association between mesenteric panniculitis and malignancies.

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.

Diagnosis of mesenteric panniculitis in the multi-detector computed tomography era. Association with malignancy and surgical history

OBJECTIVES

To assess the prevalence and associations of mesenteric panniculitis (MP) using multi-detector CT (MDCT).

METHODS

This retrospective study included 4758 consecutive patients who underwent abdomino-pelvic MDCT between January 2012 and December 2014 at Jordan University Hospital, Amman, Jordan. Radiological database was searched for MP diagnosis and patients with suspected MP were re-evaluated by an experienced radiologist to confirm the diagnosis. Data on all patients with confirmed MP diagnosis were subsequently collected and analyzed.

RESULTS

Computed tomography features of MP were identified in 90 patients (41 males, 49 females), a prevalence of 1.9%. Mesenteric panniculitis was identified in both asymptomatic and symptomatic patients. Malignancy was found in 28 MP patients (31%) and 44 of the MP patients (49%) had prior history of abdomino-pelvic surgery. Mesenteric panniculitis was significantly more frequently associated with prior abdomino-pelvic surgery (p=0.0001) and the likelihood of associated malignancy in patients with MP was 2.1-fold higher than in patients without MP (p=0.0013). Conclusion: Mesenteric panniculitis can be reliably diagnosed by MDCT due to its typical CT appearance. Its identification is important because of its significant association with malignancy and because it represents one of the differential diagnoses in patients with nonspecific symptoms referred for abdomino-pelvic CT.

Association between misty mesentery with baseline or new diagnosis of cancer: a matched cohort study

We compared the prevalence of a baseline diagnosis of cancer in patients with and without misty mesentery (MM) and determined its association with the development of a new cancer. This was a retrospective, HIPAA-compliant, IRB-approved case-control study of 148 cases and 4:1 age- and gender-matched controls. Statistical tests included chi-square, t-test, hazard models, and C-statistic. Patients with MM were less likely to have cancer at baseline (RR=0.74, p=0.003), but more likely to develop a new malignancy on follow-up (RR=2.13, p=0.003; survival analysis HR 1.74, p=0.05). MM may confer an increased probability of later developing cancer, particularly genitourinary tumors.