A case of malignant peritoneal mesothelioma suggesting the utility of combining double-contrast radiography and endoscopy with computed tomography for diagnosis

Our plain-English summary of A case of malignant peritoneal mesothelioma suggesting the utility of combining double-contrast radiography and endoscopy with computed tomography for diagnosis, by H. Saito, S. Hasuda, J. Nasu, et al (Clinical Journal of Gastroenterology, 2017).

The study

• Authors: H. Saito, S. Hasuda, J. Nasu, M. Kitaoka, I. Matsushita
• Journal: Clinical Journal of Gastroenterology
• Published: 2017;10(4):371-376
• Type of article: Case report
• Cited by: 2 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

A 68-year-old woman presented with abdominal pain, weight loss, and vomiting. Enhanced computed tomography (CT) showed slightly increased density in the mesentery and edema of the third portion of the duodenum and proximal jejunum. Little ascites, but no primary lesion, lymph node metastases, or distant metastases, were observed. Endoscopic findings included erythema and edema in the distal duodenum and proximal jejunum without epithelial lesions. Double-contrast radiography revealed transverse ridging with convergence, suggesting a serosal lesion. We suspected disease involving the serosa, such as mesenteric panniculitis. However, the lesion was definitively diagnosed as malignant peritoneal mesothelioma based on a biopsy specimen obtained at laparotomy. The combination of transverse ridging with convergence on double-contrast radiography and mucosal edema without epithelial lesions on endoscopy was consistent with a disorder involving the serosa. Transverse ridging with convergence is helpful to diagnose serosal pathology such as malignant peritoneal mesothelioma. Combining the findings of double-contrast radiography and endoscopy with computed tomography may facilitate diagnosis of malignant peritoneal mesothelioma. Thus, in case of increased density of mesentery and wall thickness on CT image with transverse ridging with convergence on double-contrast radiography and without epithelial lesion on endoscopy, malignant peritoneal mesothelioma must be considered.

In plain English

This case report described a 68-year-old woman in Kumamoto, Japan. She had abdominal pain, weight loss of more than 10 kg over half a year, and vomiting. It was uncertain whether she had been exposed to asbestos. Enhanced CT showed slightly increased density in the mesentery and swollen thickening of the third portion of the duodenum and proximal jejunum. It showed little ascites, no other primary tumor, and no distant or lymph node metastases. Endoscopy showed redness and swelling without changes suggesting tumors of the bowel lining, but could not pass the narrowing. Double-contrast barium radiography showed a fold pattern called transverse ridging with convergence. This suggested the disease came from the bowel's outer (serosal) layer. Before surgery no definitive diagnosis could be made; doctors suspected a serosal disorder such as mesenteric panniculitis. Biopsy at surgery led to a diagnosis of epithelioid malignant peritoneal mesothelioma. She received palliative care and died 3 months after diagnosis. The authors concluded that combining CT with radiography and endoscopy may help suggest this diagnosis. They noted the radiography sign is not specific to mesothelioma.

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: case report (single patient)
• Who was studied: One 68-year-old woman transferred to Kumamoto Chuo Hospital, Kumamoto, Japan, with abdominal pain, weight loss of more than 10 kg over half a year, and vomiting for about a month; dates of care not stated
• Exposure: Asbestos exposure was uncertain; no fiber type, job or dose was reported
• Main results:
  • Enhanced CT showed slightly increased density in the mesentery and edematous thickening of the third portion of the duodenum and proximal jejunum, with little ascites and no other primary lesion, distant metastases or lymph node metastases
  • Endoscopy showed erythema and edema of the third portion of the duodenum and proximal jejunum, with no mucosal changes suggesting epithelial tumors in the area examined; the scope could not pass beyond the stenosis
  • Double-contrast radiography showed marked stenosis and transverse ridging with convergence, which suggested the lesion arose from the serosa rather than the mucosa; a definitive diagnosis could not be made before surgery, and the authors suspected a serosal disorder such as mesenteric panniculitis
  • At laparotomy, numerous small nodules were seen on the serosal surface constricting the proximal jejunum, and small nodules were scattered over the small bowel and colon; immunohistochemistry was positive for mesothelin, WT-1, cytokeratin 5/6 and vimentin, and epithelioid malignant peritoneal mesothelioma was diagnosed
  • Chemotherapy was not given because of marked malnutrition and reduced performance status; the patient received palliative care and died 3 months after diagnosis
• The authors' conclusion: The authors concluded that combining CT imaging with findings on double-contrast radiography and endoscopy may be useful for suggesting a diagnosis of malignant peritoneal mesothelioma, and that transverse ridging with convergence helps identify serosal disease such as this
• Limitations the authors state:
  • Transverse ridging with convergence indicates only that a lesion is serosal and is not specific to malignant peritoneal mesothelioma
  • The proposed ischemic cause of the bowel wall thickening was not confirmed by tissue examination, because the wall of the lesion was not resected
  • The CT findings were not specific for malignant peritoneal mesothelioma, and the diagnosis was not suspected before surgery

Topics

The National Library of Medicine indexes this study under subjects our site covers: Lung cancer, Mesothelioma, Peritoneal mesothelioma.

Medical terms in this study, explained in our Lexicon: Peritoneal Mesothelioma, Endoscopy, Mesentery, Ascites, Erythema, Biopsy, Laparotomy, Pathology.

Related studies

• Peritoneal mesothelioma: the role of computed tomography in diagnosis and follow up — P.J. Guest, R.H. Reznek, et al. (1992)
• High performance of F-fluorodeoxyglucose positron emission tomography and contrast-enhanced CT in a rapid outpatient diagnostic program for patients with suspected lung cancer — P. Brocken, H.F. van der Heijden, et al. (2014)
• Preoperative computed tomography does not predict resectability in peritoneal carcinomatosis — J.D. Rivard, W.J. Temple, et al. (2014)
• Ultrasonography and computed tomography of peritoneal mesothelioma — H.C. Yeh, A.P. Chahinian (1980)
• Overall survival of pseudomyxoma peritonei and peritoneal mesothelioma patients after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy can be predicted by computed tomography quantified sarcopenia — A. Galan, P. Rousset, et al. (2018)
• Cystic appearance of a malignant peritoneal mesothelioma by ultrasonography and computed tomography: a case report — K.W. Preidler, H. Steiner, et al. (1994)

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