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A Multicystic Tumor Causing Intermittent Pain in a Young Man
ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI A Multicystic Tumor Causing Intermittent Pain in a Young Man Eva V. E. Madsen1 and Ignace H. de Hingh2 1 Department of Surgery, Amphia Ziekenhuis; and 2Department of Surgery, Catharina Ziekenhuis Eindhoven, Breda, The Netherlands
Question: A 31year-old man complained about intermittent pain in the right side of the abdomen for 1 year. He had no other complaints. History revealed an accident 15 years ago where he was hit in the right side; a doctor was never consulted at that time. During physical examination, we noted a healthy young man with a normal examination of the abdomen. Laboratory findings gave no extra information. On ultrasonography US), a well-defined mass, partly cystic with a dimension of 8 10 cm was seen. Computed tomography (CT) showed a lesion near the right colon without further characterization. MRI showed a septated lesion without infiltration in surrounding tissues (Figures A, B). The signal intensity matched with fluid or fat. US-guided histologic biopsies were taken. After pathologic examination of the peritoneum, muscular tissue and fat were identified. Hence, the pathologist concluded that the biopsy most likely was not representative. What are the findings on abdominal CT and MRI and what is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.
Conflicts of interest The authors disclose no conflicts. © 2014 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2014.07.039
Gastroenterology 2014;147:e11–e12
ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI Answer to the Clinical Challenges and Images in GI Question: Image 6: Benign Multicystic Peritoneal Mesothelioma We decided to perform a diagnostic laparotomy and incisional biopsies were taken to obtain a diagnosis; we did not perform frozen section analysis. Peroperatively, we found a multicystic tumor (Figure C). Because we thought this might be a pseudomyxoma peritonei, we consulted a tertiary medical center and referred the patient after the pathologic examination of this biopsy was final. Definitive pathologic examination showed a benign multicystic peritoneal mesothelioma (BMPM). BMPM is rare; approximately 150 cases are described worldwide and it mostly occurs in women of reproductive age. The most common symptoms are chronic or intermittent abdominal pain.1 BMPM is characterized by multilocular, thin-walled cysts filled with clear fluid. The pathogenesis remains unclear; the tumor arises from epithelial and mesenchymal structures. It does not metastasize, but can cause problems locally. Definitive preoperative diagnosis is challenging and pathology is difficult to establish based on biopsies alone. Modern imaging techniques do show the lesion; however, it is difficult to differentiate from lesions such as pseudomyxoma peritonei, sarcoma, and inflammatory lesions. The correlation between rupture of a cystic lesion of BMPM, for example, after a biopsy, and recurrence of tumor is uncertain.1 En bloc removal of the tumor is the only effective treatment, but even after radical resection the occurrence rate is about 50%.1 For this reason, a more aggressive operative approach, including cytoreductive surgery aiming to radically remove all visible tumor, followed by hyperthermic intraperitoneal chemotherapy (HIPEC) is recommended.2 HIPEC was performed at a tertiary medical center. Definitive pathology showed a radically resected multicystic mesothelioma with a diameter of 7 cm. He recovered well.
References 1. 2.
e12
Wang TB, Dai WG, Liu DW, et al. Diagnosis and treatment of benign multicystic peritoneal mesothelioma. World J Gastroenterol 2013;19:6689–6692. Sethna K, Mohamed F, Marchettini P, et al. Peritoneal cystic mesothelioma: a case series. Tumori 2003;89:31–35.
Question: A 31year-old man complained about intermittent pain in the right side of the abdomen for 1 year. He had no other complaints. History revealed an accident 15 years ago where he was hit in the right side; a doctor was never consulted at that time. During physical examination, we noted a healthy young man with a normal examination of the abdomen. Laboratory findings gave no extra information. On ultrasonography US), a well-defined mass, partly cystic with a dimension of 8 10 cm was seen. Computed tomography (CT) showed a lesion near the right colon without further characterization. MRI showed a septated lesion without infiltration in surrounding tissues (Figures A, B). The signal intensity matched with fluid or fat. US-guided histologic biopsies were taken. After pathologic examination of the peritoneum, muscular tissue and fat were identified. Hence, the pathologist concluded that the biopsy most likely was not representative. What are the findings on abdominal CT and MRI and what is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.
Conflicts of interest The authors disclose no conflicts. © 2014 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2014.07.039
Gastroenterology 2014;147:e11–e12
ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI Answer to the Clinical Challenges and Images in GI Question: Image 6: Benign Multicystic Peritoneal Mesothelioma We decided to perform a diagnostic laparotomy and incisional biopsies were taken to obtain a diagnosis; we did not perform frozen section analysis. Peroperatively, we found a multicystic tumor (Figure C). Because we thought this might be a pseudomyxoma peritonei, we consulted a tertiary medical center and referred the patient after the pathologic examination of this biopsy was final. Definitive pathologic examination showed a benign multicystic peritoneal mesothelioma (BMPM). BMPM is rare; approximately 150 cases are described worldwide and it mostly occurs in women of reproductive age. The most common symptoms are chronic or intermittent abdominal pain.1 BMPM is characterized by multilocular, thin-walled cysts filled with clear fluid. The pathogenesis remains unclear; the tumor arises from epithelial and mesenchymal structures. It does not metastasize, but can cause problems locally. Definitive preoperative diagnosis is challenging and pathology is difficult to establish based on biopsies alone. Modern imaging techniques do show the lesion; however, it is difficult to differentiate from lesions such as pseudomyxoma peritonei, sarcoma, and inflammatory lesions. The correlation between rupture of a cystic lesion of BMPM, for example, after a biopsy, and recurrence of tumor is uncertain.1 En bloc removal of the tumor is the only effective treatment, but even after radical resection the occurrence rate is about 50%.1 For this reason, a more aggressive operative approach, including cytoreductive surgery aiming to radically remove all visible tumor, followed by hyperthermic intraperitoneal chemotherapy (HIPEC) is recommended.2 HIPEC was performed at a tertiary medical center. Definitive pathology showed a radically resected multicystic mesothelioma with a diameter of 7 cm. He recovered well.
References 1. 2.
e12
Wang TB, Dai WG, Liu DW, et al. Diagnosis and treatment of benign multicystic peritoneal mesothelioma. World J Gastroenterol 2013;19:6689–6692. Sethna K, Mohamed F, Marchettini P, et al. Peritoneal cystic mesothelioma: a case series. Tumori 2003;89:31–35.