Journal of Visceral Surgery (2014) 151, 155—157
Available online at
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SURGICAL IMAGES
Intra-abdominal benign multicystic peritoneal mesothelioma I. Jouvin a,∗, A. Dohan b,c,d, P. Gergi a, M. Pocard a,c,d a
Service de chirurgie digestive et cancérologique, hôpital Lariboisière, Assistance Publique—Hôpitaux de Paris, 2, rue Ambroise-Paré, 75010 Paris, France b Service de radiologie viscérale et vasculaire, hôpital Lariboisière, Assistance Publique—Hôpitaux de Paris, 2, rue Ambroise-Paré, 75475 Paris cedex 10, France c Université Paris-Diderot, Sorbonne Paris Cité, 10, rue de Verdun, 75010 Paris, France d UMR Inserm 965, angiogenèse et recherche translationnelle, hôpital Lariboisière, 2, rue Amboise-Paré, 75010 Paris, France Available online 14 January 2014
KEYWORDS Mesothelioma peritonei; Peritoneal carcinomatosis; Cytoreductive surgery; MRI; HIPEC
Summary Benign multicystic peritoneal mesotheliomas are rare: pre-operative diagnosis relies on proper imaging. The differential diagnosis includes pseudomyxoma peritonei and other peritoneal cysts. Absence of previous surgical resection offers the best chance of success when complete resection is performed in a specialized center. We report the case of a 43 year-old man with benign multicystic peritoneal mesothelioma treated by cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. © 2013 Elsevier Masson SAS. All rights reserved.
An asymptomatic 43 year-old man was referred to our unit for fortuitously discovered peritoneal cysts. MRI showed a multiloculated lesion with dense contents demonstrated by moderate T2-weighted hypersignal while CT imaging of the lesion showed fluid density but was unable to demonstrate the multiple septa (Fig. 1). The diagnoses of pseudomyxoma peritonei (PMP) or mesothelioma peritonei (MP) were proposed. Normal tumor markers and the appearance of peri-hepatic scalloping led us to favor the diagnosis of PMP. Multidisciplinary consultation recommended surgical cytoreduction and hyperthermic intraperitoneal chemotherapy (HIPEC). A second opinion was obtained from the French National Cancer Institute network for rare peritoneal cancers (RENAPE network) to validate this therapeutic choice. Intra-operatively, peritoneal carcinomatosis consisting of multiple translucent cystic nodules (Fig. 2) was found. This specific aspect led to the diagnosis of benign multicystic peritoneal mesothelioma (BMPM) and elimination of the diagnosis of PMP. Complete excision consisted of total peritonectomy including the Douglas pouch, omentectomy, and hepatic pedicle lymphadenectomy. HIPEC completed the operation as recommended [1], using oxaliplatin (460 mg/m2 ). Pathology confirmed the diagnosis of benign MPM.
∗
Corresponding author. E-mail address: [email protected] (I. Jouvin).
1878-7886/$ — see front matter © 2013 Elsevier Masson SAS. All rights reserved. http://dx.doi.org/10.1016/j.jviscsurg.2013.12.014
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Figure 1. HASTE T2-weighted MRI axial slices through the hepatic pedicle (A), the pelvis (B) and the coronal slice (C). Corresponding enhanced-CT images in the portal vein phase (D, E, F). A, D. Collection with multiple internal septations, moderately enhanced on T2weighted sequences (arrow). The septations are not visible with CT imaging. B, E. Multiloculated pelvic fluid collection with thin septa (arrow heads) giving a ‘‘cluster of grapes appearance’’. The moderate enhancement onT2-weighted images is somewhat heterogenous within the loculations because the contents are not purely liquid (arrow). On CT scan, the septa are not visible because of their weak resolution. C, F. Peri-hepatic liquid collection that is hypodense on CT and enhanced on T2-weighted MRI images with an appearance of scalloping of the hepatic edges (arrow). This aspect is suggestive of thick liquid contents.
Intra-abdominal benign multicystic peritoneal mesothelioma
157 transformation and the 30 to 75% rate of recurrence after surgery alone have led several specialized teams to propose HIPEC [3] for this entity. No adjuvant therapy is recommended [1].
Disclosure of interest The authors have not supplied their declaration of conflict of interest.
References Figure 2. Intra-operative view. Red arrow: omental cysts. Green arrow: subhepatic multicystic mass.
The diagnosis of BMPM usually is diagnosed fortuitously but may present clinically with pelvic pain. BMPM represents only 3 to 5% of PM, whose incidence is 1 per 1 000 000 [2,3]. CT scan detects multiple cysts, sometimes with irregular enhancement of the cystic walls, although this is better seen with MRI. MRI allows differentiation between pure liquid contents and mucoid contents that are less intense on T2 weighted MRI sequences [4]. Differential diagnosis includes PMP, cystic lymphangioma with evidence of a solid component on imaging, PM, and cystic peritoneal carcinomatosis [3,5]. The gross aspect of the cysts is typical: multiple grapelike translucent cysts [2]. The rare instance of malignant
[1] Chua TC, Yan TD, Deraco M, Glehen O, Moran BJ, Sugarbaker PH. Multi-institutional experience of diffuse intra-abdominal multicystic peritoneal mesothelioma. Br J Surg 2011;98:60—4. [2] Takemoto S, Kawano R, Honda K, Nakazono A, Shimamatsu K. Benign multicystic peritoneal mesothelioma mimicking recurrence of an ovarian borderline tumor: a case report. J Med Case Rep 2012;6:126. [3] Schwartz A, Peycru T, Tardat E, Dufau JP, Jarry J, Durand-Dastes F. Peritoneal cystic mesothelioma: benign or malignant? J Chir 2008;145(5):511—2. [4] Koo PJ, Wills JS. Case 146: benign multicystic mesothelioma. Radiology 2009;251:944—6. [5] Mordi A, Rabii K, Hameed E, Lefrancq T. Intestinal obstruction complicating a mesenteric cystic lymphangioma. J Visc Surg 2012;149:e356—8.
Available online at
ScienceDirect www.sciencedirect.com
SURGICAL IMAGES
Intra-abdominal benign multicystic peritoneal mesothelioma I. Jouvin a,∗, A. Dohan b,c,d, P. Gergi a, M. Pocard a,c,d a
Service de chirurgie digestive et cancérologique, hôpital Lariboisière, Assistance Publique—Hôpitaux de Paris, 2, rue Ambroise-Paré, 75010 Paris, France b Service de radiologie viscérale et vasculaire, hôpital Lariboisière, Assistance Publique—Hôpitaux de Paris, 2, rue Ambroise-Paré, 75475 Paris cedex 10, France c Université Paris-Diderot, Sorbonne Paris Cité, 10, rue de Verdun, 75010 Paris, France d UMR Inserm 965, angiogenèse et recherche translationnelle, hôpital Lariboisière, 2, rue Amboise-Paré, 75010 Paris, France Available online 14 January 2014
KEYWORDS Mesothelioma peritonei; Peritoneal carcinomatosis; Cytoreductive surgery; MRI; HIPEC
Summary Benign multicystic peritoneal mesotheliomas are rare: pre-operative diagnosis relies on proper imaging. The differential diagnosis includes pseudomyxoma peritonei and other peritoneal cysts. Absence of previous surgical resection offers the best chance of success when complete resection is performed in a specialized center. We report the case of a 43 year-old man with benign multicystic peritoneal mesothelioma treated by cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. © 2013 Elsevier Masson SAS. All rights reserved.
An asymptomatic 43 year-old man was referred to our unit for fortuitously discovered peritoneal cysts. MRI showed a multiloculated lesion with dense contents demonstrated by moderate T2-weighted hypersignal while CT imaging of the lesion showed fluid density but was unable to demonstrate the multiple septa (Fig. 1). The diagnoses of pseudomyxoma peritonei (PMP) or mesothelioma peritonei (MP) were proposed. Normal tumor markers and the appearance of peri-hepatic scalloping led us to favor the diagnosis of PMP. Multidisciplinary consultation recommended surgical cytoreduction and hyperthermic intraperitoneal chemotherapy (HIPEC). A second opinion was obtained from the French National Cancer Institute network for rare peritoneal cancers (RENAPE network) to validate this therapeutic choice. Intra-operatively, peritoneal carcinomatosis consisting of multiple translucent cystic nodules (Fig. 2) was found. This specific aspect led to the diagnosis of benign multicystic peritoneal mesothelioma (BMPM) and elimination of the diagnosis of PMP. Complete excision consisted of total peritonectomy including the Douglas pouch, omentectomy, and hepatic pedicle lymphadenectomy. HIPEC completed the operation as recommended [1], using oxaliplatin (460 mg/m2 ). Pathology confirmed the diagnosis of benign MPM.
∗
Corresponding author. E-mail address: [email protected] (I. Jouvin).
1878-7886/$ — see front matter © 2013 Elsevier Masson SAS. All rights reserved. http://dx.doi.org/10.1016/j.jviscsurg.2013.12.014
156
I. Jouvin et al.
Figure 1. HASTE T2-weighted MRI axial slices through the hepatic pedicle (A), the pelvis (B) and the coronal slice (C). Corresponding enhanced-CT images in the portal vein phase (D, E, F). A, D. Collection with multiple internal septations, moderately enhanced on T2weighted sequences (arrow). The septations are not visible with CT imaging. B, E. Multiloculated pelvic fluid collection with thin septa (arrow heads) giving a ‘‘cluster of grapes appearance’’. The moderate enhancement onT2-weighted images is somewhat heterogenous within the loculations because the contents are not purely liquid (arrow). On CT scan, the septa are not visible because of their weak resolution. C, F. Peri-hepatic liquid collection that is hypodense on CT and enhanced on T2-weighted MRI images with an appearance of scalloping of the hepatic edges (arrow). This aspect is suggestive of thick liquid contents.
Intra-abdominal benign multicystic peritoneal mesothelioma
157 transformation and the 30 to 75% rate of recurrence after surgery alone have led several specialized teams to propose HIPEC [3] for this entity. No adjuvant therapy is recommended [1].
Disclosure of interest The authors have not supplied their declaration of conflict of interest.
References Figure 2. Intra-operative view. Red arrow: omental cysts. Green arrow: subhepatic multicystic mass.
The diagnosis of BMPM usually is diagnosed fortuitously but may present clinically with pelvic pain. BMPM represents only 3 to 5% of PM, whose incidence is 1 per 1 000 000 [2,3]. CT scan detects multiple cysts, sometimes with irregular enhancement of the cystic walls, although this is better seen with MRI. MRI allows differentiation between pure liquid contents and mucoid contents that are less intense on T2 weighted MRI sequences [4]. Differential diagnosis includes PMP, cystic lymphangioma with evidence of a solid component on imaging, PM, and cystic peritoneal carcinomatosis [3,5]. The gross aspect of the cysts is typical: multiple grapelike translucent cysts [2]. The rare instance of malignant
[1] Chua TC, Yan TD, Deraco M, Glehen O, Moran BJ, Sugarbaker PH. Multi-institutional experience of diffuse intra-abdominal multicystic peritoneal mesothelioma. Br J Surg 2011;98:60—4. [2] Takemoto S, Kawano R, Honda K, Nakazono A, Shimamatsu K. Benign multicystic peritoneal mesothelioma mimicking recurrence of an ovarian borderline tumor: a case report. J Med Case Rep 2012;6:126. [3] Schwartz A, Peycru T, Tardat E, Dufau JP, Jarry J, Durand-Dastes F. Peritoneal cystic mesothelioma: benign or malignant? J Chir 2008;145(5):511—2. [4] Koo PJ, Wills JS. Case 146: benign multicystic mesothelioma. Radiology 2009;251:944—6. [5] Mordi A, Rabii K, Hameed E, Lefrancq T. Intestinal obstruction complicating a mesenteric cystic lymphangioma. J Visc Surg 2012;149:e356—8.
