Malignant Peritoneal Mesothelioma Presenting with High Protein, High Serum-Ascites Albumin Gradient

Our plain-English summary of Malignant Peritoneal Mesothelioma Presenting with High Protein, High Serum-Ascites Albumin Gradient, by Z.P. Kerosky, C.R. Powell, P.C. Lindholm (Curēus, 2022).

The study

• Authors: Z.P. Kerosky, C.R. Powell, P.C. Lindholm
• Journal: Curēus
• Published: 2022;14(7):e27286
• Type of article: Case report
• Read it: PubMed · Publisher · Free full text

Abstract

Mesothelioma is a difficult-to-detect neoplasm that rarely develops in the peritoneum. In patients with unexplained ascites, pleural fluid analysis and ultrasonography is often the first step to achieving a diagnosis. This case report shares a unique presentation in which a patient who presented with unexplained ascites, was initially thought to have cirrhosis but was later found to have malignant peritoneal mesothelioma after cross-sectional imaging and tissue acquisition. This case illustrates the importance of a high clinical index of suspicion for mesothelioma given its variety of clinical presentations, as well as the utility of early cross-sectional imaging in such cases.

Copyright © 2022, Kerosky et al.

In plain English

This case report described a 69-year-old man with two months of abdominal swelling and early satiety. He had taken methotrexate for about 20 years for myasthenia gravis. Ultrasound showed a shrunken liver with a large amount of fluid in the abdomen (ascites), raising concern for cirrhosis. Doctors drained 8100 mL of fluid. Its serum-ascites albumin gradient (SAAG, a fluid test) was 1.3 and its protein was 3.7 g/dL, and initial cytology found no cancer. The authors wrote that these results initially made cancer seem less likely. A liver biopsy showed no fibrosis. A CT scan then showed widespread thickening of the omentum, a fatty layer in the abdomen. A biopsy of a chest wall nodule seen on PET was consistent with mesothelioma, six months after symptoms began. Only after diagnosis was he found to have significant occupational asbestos exposure during his military career. The article does not name a fiber type. He received palliative chemotherapy. The authors recommended early cross-sectional imaging in unexplained ascites and early discovery of occupational exposures.

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
• Who was studied: One patient: a 69-year-old man with a history of myasthenia gravis (on methotrexate for about 20 years), rheumatic fever, and testicular lymphoma in 1981. He presented with two months of abdominal swelling and early satiety. The authors were at US Army medical centers in Tacoma and Fort Irwin.
• Exposure: Significant occupational asbestos exposure during his military career, identified only after diagnosis. No fiber type, product, job or dose is given.
• Main results:
  • The patient had two months of abdominal swelling with early satiety. A formal ultrasound with Doppler showed a shrunken liver with large ascites, concerning for decompensating cirrhosis.
  • Paracentesis drained 8100 mL of serous fluid, with a SAAG of 1.3 and protein of 3.7 g/dL. Initial cytology did not show malignancy.
  • The authors stated that the high SAAG and the negative cytology initially placed cancer lower on the list of possible diagnoses.
  • The liver biopsy showed only mild, non-specific changes, with no fibrosis, infiltrative disease or venous outflow obstruction.
  • Contrast CT of the chest, abdomen and pelvis showed diffuse omental thickening, concerning for peritoneal carcinomatosis.
  • Biopsy of a chest wall nodule seen on PET was consistent with mesothelioma, both in appearance and on immunophenotyping.
  • Tissue diagnosis came six months after symptom onset.
  • The patient received palliative chemotherapy with carboplatin and pemetrexed at an outside institution.
• The authors' conclusion: The authors concluded that peritoneal mesothelioma is rare and difficult to diagnose, and that peritoneal fluid analysis, cytology and ultrasonography have limitations. They recommended broad cross-sectional imaging early in unexplained ascites, as well as early discovery of occupational exposures.
• Limitations the authors state:
  • The authors stated that significant liver fibrosis may have been missed by the biopsy, whose cores were 1.8 to 2.2 cm long. Further biopsies were not pursued.
  • The authors could not explain the high SAAG with certainty. They suggested fluid from the tumor may have caused a falsely high SAAG, or that advanced fibrosis was missed.

Topics

Medical terms in this study, explained in our Lexicon: Peritoneal Mesothelioma, Ascites, Mesothelioma, Neoplasm, Peritoneum.

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