Malignant Peritoneal Mesothelioma as a Rare Cause of Dyspeptic Complaints and Ascites: A Diagnostic Challenge

Our plain-English summary of Malignant Peritoneal Mesothelioma as a Rare Cause of Dyspeptic Complaints and Ascites: A Diagnostic Challenge, by S. Marques de Sousa, F. Pereira, M. Duarte, et al (GE Portuguese Journal of Gastroenterology, 2020).

The study

• Authors: S. Marques de Sousa, F. Pereira, M. Duarte, M. Marques, D. Vázquez, C. Marques
• Journal: GE Portuguese Journal of Gastroenterology
• Published: 2020;27(3):197-202
• Type of article: Case report
• Cited by: 1 article, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Introduction: Malignant peritoneal mesothelioma (MPM) is a rare malignancy of the mesothelial cells in the peritoneum. The best-defined risk factor is asbestos exposure, but germline mutations in BAP1 also increase susceptibility to this tumor. The diagnosis of MPM is challenging since clinical manifestations are often nonspecific.

Case Presentation: We describe a case of MPM in a 53-year-old former construction worker with prior asbestos exposure. The clinical presentation was a 3-month history of dyspeptic complaints. As initial workup, abdominal ultrasound and upper gastrointestinal endoscopy were performed. Chronic gastritis due to Helicobacter pylori was detected, which was promptly treated but without symptom relief. Abdominal ultrasound showed small volume ascites with hyperechogenic foci, which was later confirmed on computed tomography scan showing the presence of peritoneal nodules in the greater omentum and mesentery. A thorough investigation was conducted based on the suspicion of peritoneal carcinomatosis. A non-peritoneal primary tumor was not found. Ascitic cytology and immunocytochemical studies were suggestive of mesothelioma. He underwent exploratory laparotomy and inoperable peritoneal disease was observed. Peritoneal biopsy confirmed epithelioid-type MPM. Systemic therapy was initiated with platinum plus pemetrexed with good response. The last follow-up was 38 months after the diagnosis.

Discussion/conclusion: The diagnosis of MPM is challenging since it requires a high degree of suspicion. MPM has a poor prognosis. The standard of treatment recommended is cytoreductive surgery with hyperthermic intraperitoneal chemotherapy. For those who are inoperable, systemic therapy with pemetrexed-cisplatin combination is the alternative. Given the infrequency of disease, it is imperative to ensure patient participation in clinical trials with the purpose of treatment standardization.

Copyright © 2019 by S. Karger AG, Basel.

In plain English

This article was a case report describing one man, aged 53, with malignant peritoneal mesothelioma, a cancer of the lining of the abdomen. He was an ex-smoker and former construction worker with 5 years of asbestos exposure that began at age 14. The article did not name a fiber type. He first had 3 months of stomach complaints. Treatment for a Helicobacter pylori stomach infection did not fully resolve them. Scans showed fluid and nodules in the abdomen. Tests of the fluid suggested mesothelioma, and a biopsy confirmed the epithelioid type. Surgery to remove the tumor could not be done because the disease was too widespread. Chemotherapy first brought stable disease. After the disease progressed, a second treatment brought partial response. At the last follow-up, 38 months after diagnosis, the disease was stable. His brother also had peritoneal mesothelioma, after heavier exposure. The authors considered both cases linked to work with asbestos and not to an inherited BAP1 mutation, although this mutation was not tested. The authors concluded that patients with this rare disease should take part in clinical trials.

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 53-year-old man, an ex-smoker and former construction worker, seen at an internal medicine department in Póvoa de Varzim and an oncology center in Porto, Portugal; no dates of care given
• Exposure: occupational asbestos exposure as a construction worker for 5 years, starting at age 14; fiber type not stated. His brother, also a construction worker, had more than 10 years of exposure.
• Main results:
  • The patient first presented with a 3-month history of dyspeptic (indigestion-type) complaints
  • Treatment for Helicobacter pylori did not fully resolve the symptoms
  • CT scan showed small volume ascites (abdominal fluid) with peritoneal nodules in the greater omentum and mesentery
  • Cells in the ascitic fluid expressed calretinin, CD10 and CK7, suggesting mesothelioma
  • At laparotomy the disease was too extensive for planned cytoreductive surgery with HIPEC
  • Peritoneal biopsy confirmed epithelioid-type malignant peritoneal mesothelioma
  • First-line chemotherapy (cisplatin and pemetrexed, then pemetrexed alone after a hypersensitivity reaction) gave stable disease as best response over 8 cycles
  • After progression, 6 cycles of carboplatin plus pemetrexed gave a partial response
  • At the last follow-up, 38 months after diagnosis, the patient had stable disease
  • Time from first asbestos exposure to diagnosis was 39 years
  • Testing for a germline BAP1 mutation was not done, since only his brother had the disease
  • The authors considered both brothers' cases linked to occupational asbestos exposure, not to family history or a possible BAP1 mutation
• The authors' conclusion: The authors concluded that malignant peritoneal mesothelioma is hard to diagnose and has a poor prognosis because treatment options are limited, and that patients should be enrolled in clinical trials to standardize treatment.

Topics

Medical terms in this study, explained in our Lexicon: Peritoneal Mesothelioma, Ascites, Mesothelial Cells, Peritoneum, Asbestos Exposure, Germline Mutation, BAP1, Ultrasound.

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