Diagnosis and treatment of benign multicystic peritoneal mesothelioma

Thinking outside the pelvis: benign peritoneal multicystic mesothelioma of the ascending colon

Benign peritoneal multicystic mesothelioma is a rare tumor of the visceral peritoneum. The authors present an atypical case of a 74-year-old man who presented with a multicystic mesothelioma of the ascending colon.

Thoracic benign cystic mesothelioma

BACKGROUND

Benign cystic mesotheliomas (BCMs), also known as multilocular mesothelial inclusion cysts, inflammatory inclusion cysts or multicystic mesothelial proliferation, are frequently observed in females and are localised localised in the pelvic peritoneum. They are rarely present in the thoracic and mediastinal areas; however, these locations have been reported in a few cases in the literature.

CASE PRESENTATION

We present the case of a woman with an intrathoracic BCM. A 28-year-old female patient presented with a cystic mass of 8 × 6 × 6 cm in the left hemithorax shown by computed tomography of the thorax. The patient underwent cystic mass excision with video-assisted thoracoscopic surgery (VATS), which was completed without complications. The diagnosis was confirmed histopathologically after the surgical resection.

CONCLUSIONS

Due to BCMs' non-specific clinical symptoms and radiological imaging, preoperative diagnosis is difficult, and they are often confused with pericardial cysts. There is no standard treatment protocol; however, VATS and en bloc resection are the most frequently used treatment options for mediastinal localization. Since these lesions slow proliferation rates have the potential for local recurrence and low malignant transformation, close follow-up is recommended. In this case report, we aimed to present a rare BCM case with intrathoracic paracardiac localization was completely excised through VATS. No recurrence has been detected in three years of follow-up.

Benign multicystic peritoneal mesothelioma occurring in bilateral inguinal canals metachronously: a case report

BACKGROUND

Benign multicystic peritoneal mesothelioma (BMPM) is a benign tumor that usually occurs in middle-aged females. Although several published studies have reported the occurrence of this tumor in the abdominal cavity, few have documented its development in the inguinal region.

CASE PRESENTATION

We present a case of a 48-year-old female presenting with a bulge in her left inguinal region. Physical examination revealed a golf ball-sized nodule in the left inguinal region that could not be pushed back into the abdominal cavity. Contrast-enhanced computed tomography showed a multicystic tumor; therefore, the patient was diagnosed with inguinal hernia or hydrocele of the Nuck's canal. We performed surgical resection and hernia repair using the mesh plug method. The resected specimen was 80 mm in length and contained a multicystic tumor. Pathological examination showed that the cyst wall was lined by a single layer of cuboidal to single layer squamous epithelium. Immunohistochemistry revealed positivity for calretinin in the epithelial cells, for which a diagnosis of BMPM was established. The patient returned to our hospital after 5 years with symptoms similar to the previous episode, but this time in the right inguinal region. Imaging studies showed a tumor in the right inguinal region with the same characteristics as the previous one. The patient underwent tumor resection and hernia repair using the same technique. The resected tumor was 45 mm in length and had characteristics similar to the previously resected tumor. The presence of calretinin and D2-40 on immunohistochemistry led to the diagnosis of BMPM. There was no recurrence of BMPM for 33 months after the secondary surgery.

CONCLUSIONS

Here we present the first report of metachronous BMPM occurring in bilateral inguinal canals. Although the pathogenesis of BMPM remains unclear, reactive changes have been suggested to cause tumors originating from the groin. The treatment of choice for BMPM is surgical resection. For diagnosis, pathological examination with immunostaining can be useful. The most appropriate postoperative follow-up for inguinal BMPM is controversial, and the accumulation of more inguinal BMPM cases is needed.

Quistes mesoteliales benignos con posible origen en las trompas de Falopio resecados por laparotomía

Introducción. Los quistes mesoteliales benignos son una entidad poco frecuente, que ocurren especialmente en mujeres en edad reproductiva. Se deben a una proliferación anómala del mesotelio que puede ser originada en varias estructuras intraabdominales e inicialmente es asintomática. Caso clínico. Se presenta el caso de una mujer de 20 años con un cuadro sugestivo de neoplasia maligna, en quien se confirmó el diagnóstico de quiste mesotelial originado en la trompa de Falopio derecha. Se realizó tratamiento quirúrgico exitoso. Discusión. A pesar de la estrecha relación de esta entidad con el útero y los ovarios, no se encuentran reportes de quistes mesoteliales originados a partir de las trompas de Falopio. El tratamiento de los quistes mesoteliales es quirúrgico y en el caso de esta paciente se hizo con la finalidad de mejorar los síntomas y erradicar la enfermedad. Las decisiones fueron tomadas basadas en la opinión de expertos en oncología en una junta de tumores gastrointestinales. Conclusiones. Los quistes mesoteliales son neoplasias de baja incidencia, pero se deben tener en cuenta como diagnóstico diferencial de los tumores abdominales. Se presenta el caso de una paciente tratada de forma quirúrgica con resultados exitosos y seguimiento a un año sin recurrencias

Pancreatic mesothelial cyst

A 60-year-old woman was investigated for abdominal pain and increasing asthenia. Abdominal CT revealed a 25 mm hypodense cystic lesion in the tail of the pancreas. MRI showed a multiloculated cystic lesion, T1-hypointense and T2-hyperintense lesion, without wall enhancement. Endoscopic ultrasound detected a 25 mm multi-loculated cystic lesion, with regular margin and without pancreatic duct communication. Diagnosis of pancreatic mucinous cystadenoma was discussed and the patient was referred to surgery. She underwent distal pancreatectomy with spleen preservation. Pathological examination revealed the diagnosis of pancreatic mesothelial cyst. Histologically, the cyst was multiloculated, lined by cuboidal epithelium, ovoid nuclei and amphophilic cytoplasm, without mucin deposition or cytological atypia. Immunohistochemistry examination revealed positive staining for cytokeratin 5/6, vimentin and calretinin. At 1-year follow-up, she is in her usual health, without any symptoms.

Multicystic peritoneal mesothelioma treated with complete cytoreductive surgery, peritonectomy and hyperthermic intra-peritoneal chemotherapy-A case report

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Multicystic Peritoneal mesothelioma is a distinct type of peritoneal mesothelioma with borderline malignant potential and tendency to recur after tumor debulking.

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Morphologically MCPM has grapelike cysts filled with clear fluid and microscopically it has cystic spaces lined by cuboidal epithelium.

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There are areas of increased proliferative activity in the background of benign cyst representing potential for aggressiveness.

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Peritoneal free floating cysts can be formed from disintegration of main mass and deposit in other areas to form metastatic deposits.

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Comprehensive treatment – Complete cytoreduction, involved peritonectomy and HIPEC is required for treatment of macroscopic tumor and microscopic residue.

Background

Multicystic Peritoneal mesothelioma is a rare and distinct variety of peritoneal mesothelioma with borderline malignant potential. Conventional Tumor bulking has been associated with recurrence of 45–50 %. Hence a comprehensive treatment with Complete cytoreductive surgery with involved field peritonectomy (CRS) and Hyperthermic Intra-peritoneal chemotherapy (HIPEC) is being increasingly adopted for MCPM.

Case presentation

A 47 year old lady evaluated for peri-menopausal disturbance was diagnosed to have a multicystic lesion in the pelvis. With a preoperative suspicion of diagnosis of pseudomyxoma peritonei, CRS with HIPEC was planned. On exploration a diffuse multicystic mass was found in omentum and pouch of douglas with typical morphological features of MCPM. Complete cytoreduction was achieved with anterolateral and sub-diaphragmatic peritonectomy, omentectomy and panhystrectomy. HIPEC was performed with cisplatin 50 mg/m² for 40 min. Pathological examination revealed MCPM of omentum and uterine surface with focal clusters of mesothelial proliferation. However there was low proliferative activity 1–2 %.

Discussion

MCPM presents with wide spread peritoneal spread but with relative sparing of visceral invasion. Literature review suggests the disease spread is similar to PMP and treatment with CCRS and HIPEC has yielded long term survivals in MCPM.

Conclusions

This patient with voluminous disease burden in abdomen required surgical management and HIPEC for her condition. Whether CCRS alone without HIPEC can be an alternative for limited disease will be interesting research for future clinical reports.

Pulmonary Lymphangioleiomyomatosis originates in the pleural mesothelial cell population

Lymphangioleiomyomatosis (LAM) is a cystic lung disease mainly affecting women, in which degradation of the lung parenchyma is associated with a cell of unknown provenance, known as a LAM cell. LAM cells carry TSC2 mutations and can be identified in the lung parenchyma by their expression of both smooth muscle actin and antigens characteristic of melanocytes and melanocytic tumors. The nature of the cell-of-origin of LAM is controversial, and despite continued research effort remains elusive. Further, it has not been possible to culture pulmonary LAM cells in vitro, and current research relies on cells and animal models which may not recapitulate all features of the disease. We noted aberrant expression of melanoma antigens in pleural mesothelial cells in lung tissue from LAM patients, indicating that these cells could be the precursors of parenchymal LAM cells. We hypothesise that loss of tuberin function following TSC2 mutation in the mesothelial cell lineage gives rise to the cell-of-origin of pulmonary LAM (P-LAM), and of other associated conditions commonly noted in LAM patients. The unique properties of mesothelial cells provide a straightforward explanation of the diverse presentation of LAM.

Benign multicystic peritoneal mesothelioma: literature review and update

Benign multicystic peritoneal mesothelioma (BMPM) is a rare peritoneal tumor diagnosed predominantly in pre-menopausal women. Associated risk factors include endometriosis and pelvic inflammatory disease in women, and prior abdominal surgery in both genders. To date, the pathogenesis of this disease remains controversial with possible etiologies, including a neoplastic versus a reactive process. Given the risk factors, some authors believe that this disease is secondary to a reactive process. However, because some studies describe cases where there is no prior surgical history or inflammatory milieu present, and because of this entity’s predilection for recurrence, some authors believe the origin to be neoplastic. Some genetic and familial associations have also been reported. Malignant transformation is extremely rare, with only two cases reported in the literature, despite the recurrence potential. Like the etiology, the name of this entity is also controversial. Some authors prefer the term “peritoneal inclusion cyst (PCM)” instead of “benign cystic mesothelioma” and argue that the term mesothelioma should only be used when there is evidence of atypia. Most cases of BMPM are discovered incidentally. Others reflect sequela of tumor mass effect. It appears intra-operatively as large, multi-focal, cystic lesions in the peritoneal and pelvic cavity. Diagnosis is achieved through surgical sampling with histopathological examination. Immunobiologically, BMPM exhibits multiple small cystic spaces with flattened lining containing calretinin positive cells without atypical features, mitotic figures, or tissue invasion. Treatment includes cytoreductive surgery. Here we present a case of BMPM in a 60-year-old male – a rare disease in an uncommon patient population.

Multicystic peritoneal mesothelioma: a systematic review of the literature

Multicystic peritoneal mesothelioma (MCPM) is a particularly rare and benign neoplasm that arises from the peritoneum in reproductive aged females. Its etiopathogenesis is still unclear. The current prevailing theory supports the idea that the tumor is the result of an excessive inflammatory process. Because of a lack of clinical and imaging presentation, the diagnosis is intricate, and heavily relies on case reports and short studies. A histological analysis with immunohistochemistry is required for a definitive diagnosis. To date, there is no standard treatment recommended for MCPM. However, some studies suggest proceeding with a cytoreductive surgery and a hyperthermic intraperitoneal chemotherapy combining CISPLATIN and DOXORUBICIN, due to a high incidence of recurrence rate after medical treatment or surgery alone and potential malignant transformation.

Benign Multicystic Peritoneal Mesothelioma (BMPM) as a rare cause of abdominal pain in a young male: case report and review of the literature

Benign Multicystic Peritoneal Mesothelioma (BMPM) is a rare benign cystic neoplasm that arise from the peritoneum, typically found in young females (83%), with a high incidence of local recurrence after resection (almost 50% of cases). Fewer than 200 cases have been reported worldwide in 2017. Due to its rarity and the lack of a classical clinical presentation, the diagnosis pre-operatively is challenging; moreover a great part of the literature is composed of case reports and small group studies. Nowadays, guidelines are still not available, and treatment is en bloc resection of the lesion. Some authors suggest the use of Hyperthermic Intraperitoneal Chemotherapy (HIPEC) associated with the surgical approach, even if comparative data on recurrence and complications are lacking. We report a case of BMPM diagnosed in a 40-year-old male who underwent an exploratory laparoscopy and complete excision of the neoformation. Pathology confirmed the presence of a BMPM.

Benign Multicystic Peritoneal Mesothelioma in a Male Patient with Previous Wilms' Tumor: A Case Report and Review of the Literature

Benign multicystic peritoneal mesothelioma (BMPM) is a rare condition, more common in females of reproductive age, which arises from the peritoneal mesothelium. A 33-year-old male presented to our unit with abdominal pain and constipation. His past medical history included a previous unilateral nephrectomy for Wilms' tumor and the previous incidental finding of some intra-abdominal cystic formations at the level of the mesentery. After performing a CT scan, an exploratory laparotomy was done and a voluminous cystic mesenteric mass, composed of 3 confluent formations, was observed. Some other similar but significantly smaller lesions were found. An en bloc resection of the mesenteric mass together with the corresponding intestinal loops, an appendicectomy, and some peritoneal biopsies were performed. The postoperative period was complicated by a peritonitis due to dehiscence of the intestinal anastomosis, which required another operation, and a delayed return of normal bowel function, which was resolved through prokinetic therapy. Through histological examination, a BMPM was diagnosed. At 8 months of follow-up, the patient is free of symptoms. BMPM exact etiopathogenesis still remains uncertain. Given his high recurrence rate, a long-term follow-up is recommended.

Benign multicystic mesothelioma and peritoneal inclusion cysts: are they the same clinical and histopathological entities? A systematic review to find an evidence-based management

PURPOSE

Peritoneal mesothelial cysts (PMC) are a clinical dilemma because of their true pathogenic nature. Many definitions have been associated with PMC, including "benign multicystic mesothelioma", "cystic mesothelioma", "multilocular peritoneal inclusion cysts", ''inflammatory cysts of the peritoneum" or "postoperative peritoneal cyst".

METHODS

We herein performed a systematic review of the literature focusing on clinical and histopathological aspects of PMC, diagnosis, and therapies. Moreover, we described our experience with a case of PMC in a young female.

RESULTS

Since there is often a history of prior surgery or inflammatory disease, most authors consider PMC of reactive origin. However, in some cases they occur without any documentable signs of disease or injury. A variety of clinical findings can complicate the preoperative assessment and a multitude of histological pictures may potentially lead to a misdiagnosis. The absence of a uniform treatment strategy and lack of long-term follow-up often hinder the accurate definition leading to unnecessary or unnecessarily aggressive therapy.

CONCLUSIONS

PMC are more common than had previously been thought. Most authors consider them non-neoplastic; thus the designation of "peritoneal inclusion cyst" is preferable. The term "mesothelioma" should be used only in cases of histological evidences of atypia. The high rates of recurrence suggest that the goal of treatment should not be necessarily complete eradication, but symptomatic relief through individualized treatment. This is a topic of particular importance, especially in young female where recurrence rates could be lower than those reported in adults and where an improperly aggressive treatment could have repercussions on fertility.

Multiloculated mesothelial cyst presenting as a malignant mimic

A 46-year-old woman was referred for a second opinion regarding an intra-abdominal mass discovered on imaging performed for abdominal pain and distension. The tumour appeared to involve the small bowel, left colon and mesentery and was initially thought to be consistent with an infiltrative tumour or loculated mucinous ascites. Due to the unusual appearance of the tumour and suspicion for an omental-based mass, a laparoscopic resection was recommended to the patient. Intraoperatively, the tumour was found to be a multiloculated, benign appearing, omental cyst without involvement of the bowel and was completely resected laparoscopically. Pathology demonstrated a multiloculated peritoneal mesothelial cyst.

Detection and management of retroperitoneal cystic lesions: A case report and review of the literature

The identification of cystic lesions within the retroperitoneal space is a rare event that poses clinicians the challenge of a difficult diagnosis and disease management. Retroperitoneal cystic lesions account for a group of lesions that range from common benign lesions (e.g., lymphoceles developing as a surgical complication) to rare aggressive malignant neoplasms. Currently, in the majority of cases, image-guided procedures allow for a pathological diagnosis to be achieved in these challenging lesions, thus offering the chance of an appropriate treatment; however, the overall clinical assessment of retroperitoneal cysts is highly demanding. The present study reports the management of a representative clinical case, presenting with a voluminous cystic mass able to dislocate cave vein, whose diagnosis was preceded by a deep vein thrombosis. Computed tomography-scan and ultrasound guided percutaneous drainage were performed to achieve the diagnosis. Following the discussion of the current case report, a review of the pathological and radiological characteristics of retroperitoneal cystic lesions is presented.

Benign Multicystic Peritoneal Mesothelioma: A Rare Condition in an Uncommon Gender

Benign Multicystic Peritoneal Mesothelioma (BMPM) is a rare condition that arises from the abdominal peritoneum. Fewer than 200 cases have been reported worldwide. BMPM usually affects premenopausal women and is extremely rare in men. Many factors are suspected to contribute to its development, such as previous surgery, endometriosis, and familial Mediterranean fever. The main management is surgical resection; however, it is estimated that the recurrence rate is up to 50%. Malignant transformation is rare. We report a case series of three male patients who were diagnosed with BMPM and were treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC).

The first case of benign multicystic mesothelioma presenting as a splenic mass

Multicystic mesothelioma (MM) is a relatively rare tumour arising in the pelvic peritoneum of the tuboovarian region of young woman. Exceptionally, MM occurs on the serosal surfaces of various organs including kidney, bladder, lymph nodes, and liver. We report here the first case of MM wherein a 58-year-old woman with a previous history of endometriosis of the right ovary presented with a large multicystic mass of the spleen. The diagnosis of MM was made on a surgical specimen after splenectomy. A histopathologic examination is always necessary for the diagnosis of MM which should be differentiated from other lesions particularly from cystic lymphangioma. At one year follow-up, the patient had no evidence of recurrence. Despite the high frequency of local recurrences, MM is a benign lesion and ‘en bloc’ surgical excision with prolonged follow-ups is the treatment of choice.

Benign multicystic mesothelioma of peritoneum complicating acute appendicitis in a man: a case report

BACKGROUND

Benign multicystic mesothelioma is a rare pathology. Few cases are reported in the medical literature and acute presentation is extremely uncommon.

CASE PRESENTATION

We describe an acute clinical presentation of the neoplasm that revealed itself with signs and symptoms attributable to acute appendicitis in a 41-year-old white man. Abdominal echography and computed tomography scans demonstrated the presence of a mass in direct contiguity with cecal fundus, but diagnosis remained unclear. Our patient underwent surgery and complete removal of the neoplasm. Only a definitive histological examination defined the nature of the lesion. No signs of relapse were demonstrated 1 year after the operation.

CONCLUSIONS

We showed that an acute presentation of a benign neoplasm represents a diagnostic and therapeutic challenge for the surgeon, because of the difficult differential diagnosis that acute presentation can sometimes pose and the trouble that an emergence treatment can imply.

Benign cystic mesothelioma of the peritoneum in a 12-year-old boy, diagnosed via telepathology

Low resource countries often have inadequate healthcare systems that, among other problems, suffer from a severe shortage of local expertise. In fields such as pathology, however, where diagnoses are mainly based on macroscopic and histological images, telemedicine can provide an opportunity to supplement the local capabilities by involving a world-wide network of experts. For this, the local pathologist can upload images to an online platform and then consult with international colleagues via teleconferencing, which can be particularly useful in rare or difficult cases. We present the case of a 12-year-old Afghan boy with benign cystic mesothelioma, an extremely rare benign tumour. Using the online platform IPath, we were able to diagnose the eighth reported case of this rare condition in a child, in collaboration with our colleagues in Afghanistan.

Multicystic benign cystic mesothelioma presenting as a pelvic mass

Background. Benign cystic mesothelioma (BCM) is a rare tumor that arises from the abdominal peritoneum with a predilection to the pelvic peritoneum. For this reason, it can often mimic gynecologic malignancies. Case. A 47-year-old perimenopausal female presented reporting several weeks of abdominal distention associated with abdominal tenderness and constipation. Computed tomography revealed a 24 cm multiloculated pelvic mass, and tumor markers were notable for an elevated CA-125. The patient was taken to the operating room for an exploratory laparotomy, total abdominal hysterectomy, bilateral salpingoophorectomy, and removal of pelvic mass. Final pathologic evaluation revealed a benign cystic mesothelioma. Conclusion. Classically these tumors present as large multicystic masses with thin-walled septations and on preoperative evaluation BCM can mimic many different disease entities including ovarian malignancies and cystic lymphangioma. Often diagnosis can only be made at time of surgery.