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Benign multicystic mesothelioma: Is histological aggressiveness a prognostic of local recurrence?
Abstracts
ID: 801 Cutaneous metastases like first manifestation in a neoplasia G. Lara, J.J. Hernández, A. Peláez, F. Escobar, M.M. Molina, E. Mené Service Internal Medicine, University Hospital Rafael Méndez, Lorca, Spain
e153
ID: 829 Benign multicystic mesothelioma: Is histological aggressiveness a prognostic of local recurrence? P.M. Costaa,b, D. Gomesa,b, C. Pereirac, F. Ferreirac, P. Luísd, R. Estevesc,b, A. Oliveiraa,b a
62 year old male, went to emergency due to suffering from a cutaneous suprapubic lesion for two months and severe asthenia. His medical history showed arterial hypertension, hyperuricemia, an ischemic stroke in the middle cerebral artery´s territory in 2007; and he was operated from a gastric ulcer for over 30 years. Our patient was an ex-smoker for 15 years. About his family's history, the patient referred that his mother died for a gynecological cancer which failed to specify, and a sister died of kidney cancer. During the patient's history, he commented, a long the two last months, asthenia, decreased appetite and weight loss of, at least 4 kg, without apparent cause, moreover, he suffered from a suprapubic discomfort. Cardiopulmonary auscultation, exploration of limbs, and abdomen was normal, except for an injury of about 3 cm, erythematous, with an ulcerated center and hardened edges, attached to deep plane with a right inguinal adenopathy associated. Blood test showed: LDH 342U/l; hemoglobin 6.9 g/dl, being the anemia's qualities of hypochromic microcytic. Tumor makers were normal. In the anemia's study the fecal occult blood was outlined, being 4572 ng/dl. The chest radiograph revealed a small widened mediastinum. For the clinical and laboratory findings, we ruled out an infectious cause. So we thought about the probability of a primary skin cancer or skin metastases. During our differential diagnosis, we discarded primary skin cancer as squamous carcinoma, basal carcinoma Merkell cell carcinoma, due to the fact that they appear in areas exposed to the sun. On the other hand, we thought in a nodular melanoma, cutaneous T-cell lymphoma or in a neuroectodermal tumor. As cutaneous metastases, we thought it could be a sister María José's nodule which is a periumbilical cutaneous manifestation of an abdominal cancer, and we thought in a bladder or in a lung cancer too. To continue our study, we requested a CT chestabdomen-pelvic, which revealed: mass in left lung upper lobe of 3.8 × 2.4 cm, hypo dense liver lesions, irregular thickening of the transverse colon's wall and irregular thickening of the jejunum's wall, a mass of soft tissue of 1.3 × 3.1 cm and adenopathy in right iliac external chain of 2 × 1.2 cm. Giving these findings we requested a bronchoscope, colonoscopy (from both we obtained biopsy) and a cutaneous biopsy, which were informed like a poorly differentiated tumor, supports adenocarcinoma. Thanks to inmunohistochemical techniques (ck20, ck7, CDx2) we ruled out intestinal origin. Our diagnosis was: “Lung adenocarcinoma stage IV (lymph nodes, liver, intestinal and cutaneous metastases). To conclude: Cutaneous manifestations are rare tumor manifestations, being between 0.7 and 9% of tumors, associated with breast, lung, liver, color neoplasia among others. His appearance indicates progression of the disease and a poor prognosis. Treatment will be based on the potential of the primary tumor, although, it responds poorly to treatment.
Serviço de Medicina I - sector C, Hospital de Santa Maria - CHLN, EPE, Lisboa, Portugal b Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal c Serviço de Cirurgia I, Hospital de Santa Maria - CHLN, EPE, Lisboa, Portugal d Serviço de Anatomia Patológica, Hospital de Santa Maria - CHLN, EPE, Lisboa, Portugal
Objectives: Benign multicystic mesothelioma is an exceptionally rare entity (0.15/100,000/year) that mostly affects pre-menopausal women. It is suspected to arise from mesothelial cells exposed to repetitive inflammatory stimulus (previous surgery, endometriosis, inflammatory pelvic disease, Mediterranean familial fever). Radical surgical resection is the standard of care but local recurrence may be as high as 50%. Rarely malignant progression may occur (2 out of 130). The characterization of clinical and histological features predictive of local recurrence of malignant transformation may play a major role in therapeutic guidance. Methods: Report and discussion of clinical, imagiological and histological features of a medical case. Results and discussion: A 50 years old black male, native of Cape Verde, without any previous medical or surgical conditions is admitted to our ward with a 3 months progressive abdominal discomfort and palpable mass of the right quadrants. The remaining physical exam and laboratory workup are unremarkable (namely tumor markers and viral serologic test). The abdominal ultrasound (US) showed a heterogeneous intraperitoneal mass (18 cm in diameter) with multiple cystic formations extending from the lower hepatic margin to the pelvic cavity. An abdominopelvic CT scan confirmed a multicystic mass (163 × 64mm) adherent to the transverse colon and small bowel. US guided biopsy was performed revealing multiple cystic formations lined with mesothelial cells (citokeratin and calretinin positive) without atypical features, thus most compatible with the diagnosis benign multicystic mesothelioma. The patient underwent surgery with en bloc resection of the mass, right ileocolectomy, segmental enterectomy, partial cystectomy and abdominal wall resection. The pathology report confirmed the diagnosis of benign multicystic mesothelioma. There were focal areas of intestinal wall invasion as deep as the muscular layer. Whether or not this is a prognostic sign of local recurrence or malignant transformation has not been clarified. Signs of chronic appendicitis were also identified which probably constituted the stimulus for mesothelial proliferation. Conclusion: Benign multicystic mesothelioma is a rare disease where characteristics of benignant behavior may coexist with histological aggressiveness. These features may be prognostic of local recurrence or malignant transformation. doi:10.1016/j.ejim.2013.08.396
References – Metástasis cutáneas en el cáncer de pulmón: revisión de literatura a pronostico de dos casos. http://dx.doi.org/10.4464/MD.2012.40.1.5006.
ID: 844 Screening for occult cancer in patients with acute pulmonary embolism Z. Monhart, M. Zanova
– Metástasis cutáneas como primer hallazgo de carcinoma pulmonar.
Internal Department, Hospital Znojmo, Znojmo, Czech Republic
doi:10.1016/j.ejim.2013.08.395
Background: Patients with venous thromboembolism have an increased risk for occult malignancy. Limited screening for these malignancies has become common practice but little is known about
ID: 801 Cutaneous metastases like first manifestation in a neoplasia G. Lara, J.J. Hernández, A. Peláez, F. Escobar, M.M. Molina, E. Mené Service Internal Medicine, University Hospital Rafael Méndez, Lorca, Spain
e153
ID: 829 Benign multicystic mesothelioma: Is histological aggressiveness a prognostic of local recurrence? P.M. Costaa,b, D. Gomesa,b, C. Pereirac, F. Ferreirac, P. Luísd, R. Estevesc,b, A. Oliveiraa,b a
62 year old male, went to emergency due to suffering from a cutaneous suprapubic lesion for two months and severe asthenia. His medical history showed arterial hypertension, hyperuricemia, an ischemic stroke in the middle cerebral artery´s territory in 2007; and he was operated from a gastric ulcer for over 30 years. Our patient was an ex-smoker for 15 years. About his family's history, the patient referred that his mother died for a gynecological cancer which failed to specify, and a sister died of kidney cancer. During the patient's history, he commented, a long the two last months, asthenia, decreased appetite and weight loss of, at least 4 kg, without apparent cause, moreover, he suffered from a suprapubic discomfort. Cardiopulmonary auscultation, exploration of limbs, and abdomen was normal, except for an injury of about 3 cm, erythematous, with an ulcerated center and hardened edges, attached to deep plane with a right inguinal adenopathy associated. Blood test showed: LDH 342U/l; hemoglobin 6.9 g/dl, being the anemia's qualities of hypochromic microcytic. Tumor makers were normal. In the anemia's study the fecal occult blood was outlined, being 4572 ng/dl. The chest radiograph revealed a small widened mediastinum. For the clinical and laboratory findings, we ruled out an infectious cause. So we thought about the probability of a primary skin cancer or skin metastases. During our differential diagnosis, we discarded primary skin cancer as squamous carcinoma, basal carcinoma Merkell cell carcinoma, due to the fact that they appear in areas exposed to the sun. On the other hand, we thought in a nodular melanoma, cutaneous T-cell lymphoma or in a neuroectodermal tumor. As cutaneous metastases, we thought it could be a sister María José's nodule which is a periumbilical cutaneous manifestation of an abdominal cancer, and we thought in a bladder or in a lung cancer too. To continue our study, we requested a CT chestabdomen-pelvic, which revealed: mass in left lung upper lobe of 3.8 × 2.4 cm, hypo dense liver lesions, irregular thickening of the transverse colon's wall and irregular thickening of the jejunum's wall, a mass of soft tissue of 1.3 × 3.1 cm and adenopathy in right iliac external chain of 2 × 1.2 cm. Giving these findings we requested a bronchoscope, colonoscopy (from both we obtained biopsy) and a cutaneous biopsy, which were informed like a poorly differentiated tumor, supports adenocarcinoma. Thanks to inmunohistochemical techniques (ck20, ck7, CDx2) we ruled out intestinal origin. Our diagnosis was: “Lung adenocarcinoma stage IV (lymph nodes, liver, intestinal and cutaneous metastases). To conclude: Cutaneous manifestations are rare tumor manifestations, being between 0.7 and 9% of tumors, associated with breast, lung, liver, color neoplasia among others. His appearance indicates progression of the disease and a poor prognosis. Treatment will be based on the potential of the primary tumor, although, it responds poorly to treatment.
Serviço de Medicina I - sector C, Hospital de Santa Maria - CHLN, EPE, Lisboa, Portugal b Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal c Serviço de Cirurgia I, Hospital de Santa Maria - CHLN, EPE, Lisboa, Portugal d Serviço de Anatomia Patológica, Hospital de Santa Maria - CHLN, EPE, Lisboa, Portugal
Objectives: Benign multicystic mesothelioma is an exceptionally rare entity (0.15/100,000/year) that mostly affects pre-menopausal women. It is suspected to arise from mesothelial cells exposed to repetitive inflammatory stimulus (previous surgery, endometriosis, inflammatory pelvic disease, Mediterranean familial fever). Radical surgical resection is the standard of care but local recurrence may be as high as 50%. Rarely malignant progression may occur (2 out of 130). The characterization of clinical and histological features predictive of local recurrence of malignant transformation may play a major role in therapeutic guidance. Methods: Report and discussion of clinical, imagiological and histological features of a medical case. Results and discussion: A 50 years old black male, native of Cape Verde, without any previous medical or surgical conditions is admitted to our ward with a 3 months progressive abdominal discomfort and palpable mass of the right quadrants. The remaining physical exam and laboratory workup are unremarkable (namely tumor markers and viral serologic test). The abdominal ultrasound (US) showed a heterogeneous intraperitoneal mass (18 cm in diameter) with multiple cystic formations extending from the lower hepatic margin to the pelvic cavity. An abdominopelvic CT scan confirmed a multicystic mass (163 × 64mm) adherent to the transverse colon and small bowel. US guided biopsy was performed revealing multiple cystic formations lined with mesothelial cells (citokeratin and calretinin positive) without atypical features, thus most compatible with the diagnosis benign multicystic mesothelioma. The patient underwent surgery with en bloc resection of the mass, right ileocolectomy, segmental enterectomy, partial cystectomy and abdominal wall resection. The pathology report confirmed the diagnosis of benign multicystic mesothelioma. There were focal areas of intestinal wall invasion as deep as the muscular layer. Whether or not this is a prognostic sign of local recurrence or malignant transformation has not been clarified. Signs of chronic appendicitis were also identified which probably constituted the stimulus for mesothelial proliferation. Conclusion: Benign multicystic mesothelioma is a rare disease where characteristics of benignant behavior may coexist with histological aggressiveness. These features may be prognostic of local recurrence or malignant transformation. doi:10.1016/j.ejim.2013.08.396
References – Metástasis cutáneas en el cáncer de pulmón: revisión de literatura a pronostico de dos casos. http://dx.doi.org/10.4464/MD.2012.40.1.5006.
ID: 844 Screening for occult cancer in patients with acute pulmonary embolism Z. Monhart, M. Zanova
– Metástasis cutáneas como primer hallazgo de carcinoma pulmonar.
Internal Department, Hospital Znojmo, Znojmo, Czech Republic
doi:10.1016/j.ejim.2013.08.395
Background: Patients with venous thromboembolism have an increased risk for occult malignancy. Limited screening for these malignancies has become common practice but little is known about