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

Our plain-English summary of Multicystic peritoneal mesothelioma treated with complete cytoreductive surgery, peritonectomy and hyperthermic intra-peritoneal chemotherapy-A case report, by N. Padmanabhan, H. Ishibashi, K. Nishihara, et al (International Journal of Surgery Case Reports, 2020).

The study

• Authors: N. Padmanabhan, H. Ishibashi, K. Nishihara, S. Sako, K. Katayama, S. Wakama, Y. Kamada, Y. Yonemura
• Journal: International Journal of Surgery Case Reports
• Published: 2020;74:152-157
• Type of article: Case report
• Cited by: 7 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

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.

Copyright © 2020. Published by Elsevier Ltd.

In plain English

This case report described one 47-year-old woman with multicystic peritoneal mesothelioma (MCPM), a rare form of mesothelioma of the abdominal lining. She first saw a gynecologist for heavy, painful periods around menopause. MRI showed a uterine fibroma and multiple pelvic cysts, and her gynecologist first suspected a different disease, pseudomyxoma peritonei. At surgery, cysts were found in the omentum, the right paracolic gutter and the pouch of Douglas. The nearby bowel, rectum and bladder were free of tumor. Surgeons removed all visible disease, including areas of abdominal lining, the omentum and the uterus. They then gave heated chemotherapy (cisplatin) inside the abdomen. Under the microscope, the cysts were lined by mesothelial cells without atypia, with small areas of increased cell growth. A growth marker (Ki-67) was 1 to 2%, and 3% in one focal cluster. Free-floating cysts were also seen. She recovered without complications. The article does not say whether she had ever been exposed to asbestos. The authors described MCPM as unrelated to asbestos exposure and concluded that complete removal with heated chemotherapy appears to be the optimal treatment.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Single case report
• Who was studied: One 47-year-old woman treated at a teaching hospital (Kishiwada Tokushukai Hospital, Japan). She first presented to her gynecologist with peri-menopausal menorrhagia, dysmenorrhea and pallor. Her past medical, drug and social history was described as unremarkable.
• Exposure: No exposure was studied, and the article does not state whether this patient had any asbestos exposure. In their introduction, the authors describe MCPM in general as unrelated to asbestos exposure.
• Main results:
  • Before surgery, MRI showed a uterine fibroma and multiple cystic areas in the pelvis and right iliac fossa. The gynecologist's provisional diagnosis was pseudomyxoma peritonei originating from the ovary.
  • At surgery, multicystic lesions were found in the omentum, the right paracolic gutter and the pouch of Douglas next to the uterus. The patient's surgical Peritoneal Carcinomatosis Index was 6.
  • The abdomen was washed with ten liters of saline. Complete cytoreduction was achieved by peritonectomy, removal of the uterus, total omentectomy and excision of the falciform and umbilical round ligaments.
  • The patient received hyperthermic intraperitoneal chemotherapy (HIPEC) with cisplatin 50 mg/m2 for 40 minutes.
  • Pathology showed multiple cysts lined by a layer of cuboidal mesothelial cells with no atypia, with focal areas of mesothelial cell proliferation in the omentum.
  • The proliferation marker Ki-67 was low, at 1 to 2%.
  • In one focal cluster of proliferating mesothelial cells, Ki-67 was 3%.
  • Free-floating cysts were found in the peritoneal cavity.
  • The uterus contained a benign fibroma.
  • The patient recovered well with an uneventful postoperative course, and no further adjuvant therapy was indicated.
• The authors' conclusion: The authors concluded that MCPM is a borderline tumor with potential for recurrence and transformation to invasive mesothelioma. They wrote that complete cytoreduction with HIPEC appears to be the optimal treatment, and that uterus and ovarian preservation can be offered with caution to women wishing to preserve fertility.

Topics

Medical terms in this study, explained in our Lexicon: Peritoneal Mesothelioma, Cytoreductive Surgery, Chemotherapy, HIPEC, Omentum, Cisplatin.

Related studies

• Cytoreductive surgery with selective versus complete parietal peritonectomy followed by hyperthermic intraperitoneal chemotherapy in patients with diffuse malignant peritoneal mesothelioma: a controlled study — D. Baratti, S. Kusamura, et al. (2012)
• Multicystic mesothelioma: Operative and long-term outcomes with cytoreductive surgery and hyperthermic intra peritoneal chemotherapy — E. Nizri, D. Baratti, et al. (2018)
• Radiological predictors of complete cytoreduction in 59 patients with peritoneal mesothelioma treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy at a UK referral centre — A. Chandramohan, A. Thrower, et al. (2017)
• Multicystic peritoneal mesothelioma: outcomes and patho-biological features in a multi-institutional series treated by cytoreductive surgery and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) — D. Baratti, M. Vaira, et al. (2010)
• Evaluation of the cost-effectiveness of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (peritonectomy) at the St George Hospital peritoneal surface malignancy program — T.C. Chua, S. Martin, et al. (2010)
• Conversion to Complete Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Malignant Peritoneal Mesothelioma After Bidirectional Chemotherapy — F. Le Roy, M. Gelli, et al. (2017)

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