An Unpleasant Surprise: Abdominal Presentation of Malignant Mesothelioma

Our plain-English summary of An Unpleasant Surprise: Abdominal Presentation of Malignant Mesothelioma, by D.J. Uhlenhopp, A. Saliares, V. Gaduputi, et al (Journal of Investigative Medicine High Impact Case Reports, 2020).

The study

• Authors: D.J. Uhlenhopp, A. Saliares, V. Gaduputi, T. Sunkara
• Journal: Journal of Investigative Medicine High Impact Case Reports
• Published: 2020;8:2324709620950121
• Type of article: Case report
• Cited by: 2 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Malignant mesothelioma is an aggressive cancer associated with asbestos exposure with median survival time of 8 to 14 months following diagnosis. Given that mesothelial cells also line the peritoneum and pericardium, malignant mesothelioma can present in unusual sites and in patients with nonrespiratory complaints. A 73-year-old male presented to the emergency department for worsening intermittent diffuse abdominal pain for the past 3 months with associated unintentional 40-pound weight loss, early satiety, and diarrhea. He denied exposure to asbestos. Computed tomography imaging revealed multiple masses concerning for malignancy including the primary retroperitoneal mass, a mass involving the terminal ileum, and a mass in the right upper lung. Esophagogastroduodenoscopy demonstrated significant mass effect within the stomach without signs of endoluminal infiltration. Computed tomography-guided biopsy of the retroperitoneal abdominal and intramuscular paraspinal masses was performed. Stage IV epithelioid mesothelioma was confirmed when hematoxylin and eosin staining revealed pleomorphic malignancy nuclei containing a vesicular chromatin pattern and prominent nucleoli and immunohistochemical staining was positive for CK Oscar, cytokeratin 7, GATA3, calretinin, EMA, and CK5/6. He was started on cisplatin, pemetrexed, and bevacizumab but developed severe abdominal pain with pneumoperitoneum and bowel perforation 1 month later and expired shortly thereafter. To our knowledge, this represents a highly atypical presentation of malignant mesothelioma considering the involvement of the retroperitoneum with diffuse lesions in the abdominopelvic cavity and thorax (sparing the lung pleurae). This case also calls attention to the occurrence of malignant mesothelioma in patients without known asbestos exposure and the crucial role of pathology in diagnosing atypical presentations.

In plain English

This article is a case report about one patient. A 73-year-old man went to an emergency department with three months of worsening abdominal pain, a 40-pound weight loss, early fullness and diarrhea. He had worked as a science instructor and in an import/export business. The report says he had no significant exposure history, including asbestos. He was a former smoker with a 60-pack-year history. CT scans showed a 7.9 × 5.8 × 4.9 cm mass in the retroperitoneum (the space behind the abdominal lining) and a mass in the terminal ileum (the last part of the small intestine). They also showed a 4.5 cm mass in the right upper lung. That lung mass did not involve the pleura and was judged to have spread from the abdominal mass. Biopsies and tissue staining, confirmed by Mayo Clinic Laboratories, showed stage IV epithelioid malignant mesothelioma. He started cisplatin, pemetrexed and bevacizumab. Two days into the second cycle he had a bowel perforation, and he died the following day after choosing comfort care. Genetic markers (p16, BAP1) were not tested. The authors concluded that a lack of known asbestos exposure should not be used to rule out 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 (one patient)
• Who was studied: One 73-year-old man seen at an emergency department (authors based at MercyOne Des Moines Medical Center, Iowa, USA), with abdominal pain, 40-pound weight loss, early satiety and diarrhea over 3 months
• Exposure: No known asbestos exposure: the patient was a long-time community college science instructor, later in the Swedish import/export business, with no significant exposure history including asbestos. He was a former smoker with a 60-pack-year history.
• Main results:
  • Abdominal CT showed a 7.9 × 5.8 × 4.9 cm retroperitoneal mass and a 4.6 × 3.0 × 4.1 cm soft tissue mass involving the terminal ileum
  • Chest CT showed a 4.5 cm spiculated mass in the right upper lung lobe. Because it did not involve the pleura, it was felt to be a metastasis of the primary retroperitoneal mass.
  • Upper endoscopy showed the stomach being pressed from outside by an underlying mass
  • Immunohistochemical staining was positive for CK Oscar, cytokeratin 7, GATA3, calretinin, EMA and CK5/6, and negative for markers including D2-40 and WT-1
  • The diagnosis of epithelioid malignant mesothelioma with metastasis to the terminal ileum and lung was confirmed by Mayo Clinic Laboratories; it was treated as stage IV
  • Planned treatment was 21-day cycles of cisplatin, pemetrexed and bevacizumab
  • Two days after starting the second cycle, the patient returned with severe abdominal pain. He had a moderate pneumoperitoneum with bowel perforation, chose comfort care, and died the following day.
• The authors' conclusion: The authors described this as a highly atypical presentation. They concluded that known asbestos exposure was not a factor in this case and should not be used to rule out mesothelioma, and they stressed the role of pathology in diagnosing atypical presentations.
• Limitations the authors state:
  • Other markers seen in mesothelioma, such as p16 deletion and BAP1 mutation, were not tested in this patient

Topics

The National Library of Medicine indexes this study under subjects our site covers: Mesothelioma.

Medical terms in this study, explained in our Lexicon: Malignant Mesothelioma, Asbestos Exposure, Median Survival, Mesothelial Cells, Peritoneum, Pericardium, Early Satiety, Biopsy.

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