Int J Colorectal Dis (2014) 29:891–892 DOI 10.1007/s00384-014-1875-1

LETTER TO THE EDITOR

Colonic invasion induced by malignant peritoneal mesothelioma S. B. Cao & S. Jin & J. Y. Cao & J. Shen & J. W. Zhang & Y. Yu

Accepted: 14 April 2014 / Published online: 30 April 2014 # Springer-Verlag Berlin Heidelberg 2014

Novelty: Malignant peritoneal mesothelioma (MPM) is a rare disease confined to peritoneal cavities in most cases, seldom seen in intra- and extra-abdominal invasion. In addition, MPM is easy of misdiagnosis and has a poor prognosis. Here, we report a case of colonic invasion induced by MPM in order to help prevent from misdiagnosis and prolong survival time. A 53-year-old male who presented with constipation, weight loss, and occasional abdominal discomfort for 2 months was admitted to the Department of Surgical Oncology, Harbin Medical University Cancer Hospital, November 2013. He was a heavy smoker of 15 packs/month with a history of asbestos exposure in childhood and diabetes mellitus. On physical examination, he had a fixed mass in the right lower quadrant. Routine blood tests and evaluation for tumor markers CEA, CA724, CA19-9, and CA-125 were all in normal range except for a thrombocytosis of 397×109/L. A 3D-enhanced CT of the abdomen showed an irregular thickening wall of hepatic flexure of colon, and the thickener area can be reached 16.8 mm, closely adjacent to intestine. At the same time, an infiltrating mass of 67.7 mm in size, multiple small peritoneal nodules, and abdominal swelling lymph nodes can also be seen in abdominal CT. There were no remarkable findings on the endoscopic examination, and the colonoscopy suggested an infiltrating lesion located in the

S. B. Cao and S. Jin contributed equally to this work. S. B. Cao : S. Jin : J. Y. Cao : J. Shen : J. W. Zhang : Y. Yu (*) Department of Medical Oncology, Harbin Medical University Cancer Hospital, No. 150 Hapin Road, 150081 Harbin, China e-mail: [email protected] S. B. Cao e-mail: [email protected] S. Jin e-mail: [email protected]

hepatic flexure of colon, ruptured in the surface, and easily bled when touched. Laparotomy was performed, peritoneal nodules were intraoperatively found throughout the peritoneum, and the infiltrating mass had penetrated the range of serosal and right side of the peritoneum, widely planting in the peritoneum, omentum, and surface of peritoneal cavities. Necrotic tissue sample was delivered for examination, and quick pathology revealed malignancy. In addition, 2.0 cm×1.5 cm×1.0 cm omental tissue was cut for detection during surgery. Histology revealed a well-differentiated epithelioid malignant mesothelioma. It was positive for HBME-1, CK5/6, CK7, and calretinin, supporting the diagnosis of MPM. After surgery, the patient was referred to the Department of Medical Oncology. Our patient recovered well after the operation, and he had successfully accepted 2 cycles of chemotherapy of pemetrexed combined with carboplatin; unfortunately, he did not tolerate the therapy, and the disease progressed with the appearance of ascites and rectum occupation revealed by abdominal and pelvic CT. However, there are no significant abnormalities found in colonoscopy. We deemed that rectum occupation was caused by the compression of swelling lymph nodes. Oxaliplatin and capecitabine were adjusted to the following treatment, and he felt symptoms released at present. MPM is an uncommon, fatal disease arising from the peritoneum with an increasing incidence of 7–40/million and a negative prognosis of within 12 months [1]. The main risk factor for MPM is asbestos exposure, and the onset of about 60 % of MPM patients was correlated with direct or indirect asbestos contact. In addition, exposure to radiation, talc, mica, erionite, Thorotrast, SV40, and Hodgkin’s disease has also been reported to be related to MPM [2]. The most common presentations of MPM are abdominal pain and distension which resulted from the accumulation of tumors and ascites, while constipation is exceptional. MPM is usually diagnosed at advanced stage due to its nonspecific clinical and

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radiographic manifestations. MPM is confined to the peritoneal cavity in most cases and seldom involves intra- and extraabdominal organs because the typical growth pattern of MPM is extensive, not infiltrative. However, there are still rare cases of liver, lung, bone, and lymph node involvement induced by MPM [3]. Up to date, there is rarely reported colonic invasion of MPM. Colon involvement by MPM presents as bowel obstruction, being easily misdiagnosed as digestive diseases. In addition to multiple etiological factors and different presentations and being highly aggressive, MPM is also characterized as treatment-resistant. However, treatment strategies of MPM have evolved from single chemotherapy to combined modality therapy of cytoreductive surgery (CRS), heated intraperitoneal chemotherapy (HIPEC), radiotherapy, and targeted therapy at present. With CRS and HIPEC, the median survival of patients can be increased to 92 months, with a 5year overall survival of 63 % [4]. Radiation is seldom used because of the tolerated dose of some important abdominal organs, low response rate, and adverse reactions of intestinal obstruction and adhesions. The patient did not accept HIPEC because of adhesions of intestine and lymph nodes. All in all, combined modality therapy and individualized therapy will contribute to a better prognosis. These results suggest that MPM should be considered in the differential diagnosis of difficult defecation. Awareness of such atypical presentations of mesothelioma may help to make a correct diagnosis.

Int J Colorectal Dis (2014) 29:891–892 Acknowledgments The authors thank Dr. XM Li from the Department of Pathology, Harbin Medical University Cancer Hospital, for pathological diagnosis of this case. This work was supported by Wujieping Foundation (No: 320.6750.12204), Young People Research Fund for the grant National Natural Scientific Foundation of China (No: 81201828), Young People F ou n d a t i o n o f H e i lo n g j i a n g P r o vi n c i a l o f C h i n a (N o : QC2012C013) and National Natural Scientific Foundation of China (No: 81101758).

Conflict of interest None.

References 1. Robinson BW, Lake RA (2005) Advances in malignant mesothelioma. N Engl J Med 353:1591–1603 2. Sharma H, Bell I, Schofield J et al (2011) Primary peritoneal mesothelioma: case series and literature review. Clin Res Hepatol Gastroenterol 35:55–59 3. Nagata S, Tomoeda M, Kubo C et al (2011) Malignant mesothelioma of the peritoneum invading the liver and mimicking metastatic carcinoma: a case report. Pathol - Res Pract 207:395– 398 4. Tan GH, Cheung M, Chanyaputhipong J, Soo KC, Teo MC (2013) Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal mesothelioma. Ann Acad Med Singap 42:291–296

Colonic invasion induced by malignant peritoneal mesothelioma.

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