Rapid Progression of Malignant Peritoneal Mesothelioma Mimicking a Postoperative Complication in a Young Woman: A Case Report

Our plain-English summary of Rapid Progression of Malignant Peritoneal Mesothelioma Mimicking a Postoperative Complication in a Young Woman: A Case Report, by P.C. Altshuler, A.L. Newman, J.A. Garibay (The American Journal of Case Reports, 2024).

The study

• Authors: P.C. Altshuler, A.L. Newman, J.A. Garibay
• Journal: The American Journal of Case Reports
• Published: 2024;25:e942948
• Type of article: Case report
• Cited by: 3 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

BACKGROUND Malignant peritoneal mesothelioma is a rare disease with a poor prognosis that often presents with vague symptoms and inconclusive laboratory test results. Causes include industrial pollutants, primarily asbestos, and certain genetic mutations, such as BAP1. Due to the nonspecific symptoms, it is often incidentally diagnosed during or after other surgical procedures. CASE REPORT A 35-year-old healthy woman underwent an uncomplicated laparoscopic left salpingo-oophorectomy for a symptomatic large ovarian mature cystic teratoma. She subsequently presented with late-onset postoperative fever, leukocytosis, and multiple intra-abdominal masses. Following an exploratory laparotomy, extensive infectious disease evaluation, and multiple biopsies requiring interdisciplinary collaboration, malignant peritoneal mesothelioma was diagnosed by positive histologic staining of an omental biopsy for D2-40 and CK5/6. This first specimen was positive for BAP1, with the second, a liver biopsy, testing negative for BAP1. The tumor cell testing was also notable for mutations in NF2, MLL2, and ARID1A, and the hereditary cancer genetic testing was overall unremarkable. Her disease progressed rapidly, and she died 6 months after her initial procedure. CONCLUSIONS This case of rapidly developing malignant peritoneal mesothelioma following surgical management of an ovarian mature teratoma highlights the complexity in diagnosing a rare disease that presents with nonspecific symptoms in an otherwise young and healthy woman. The rapid disease course was likely accelerated by expansive intraperitoneal spread and multiple somatic oncogenic mutations in BAP1, NF2, MLL2, and ARID1A. Gynecologists should keep a broad differential for postoperative complications, as occult malignancies can present with symptoms that mimic postoperative complications.

In plain English

This was a case report about one 35-year-old Hispanic woman who had her left ovary and fallopian tube removed because of a large benign ovarian cyst (a mature cystic teratoma). No cancer was found in the removed tissue. Four weeks later she returned with fever, abdominal pain and a high white blood cell count, and scans showed masses first thought to be abscesses. After further surgery, infection testing and two biopsies, she was diagnosed with stage IV malignant peritoneal mesothelioma, epithelioid subtype. The tumor carried mutations in several genes, including NF2, MLL2 and ARID1A, and the liver biopsy tested negative for BAP1. Inherited-cancer gene testing found no clinically significant mutations. She denied prior known asbestos exposure. She received chemotherapy and died 6 months after her first operation. The authors concluded that her rapid decline was likely accelerated by the tumor's spread inside the abdomen, including seeding at surgical sites, and by its mutations. They concluded that gynecologic surgeons should keep a broad range of possible diagnoses in mind for postoperative complications. They noted she died before additional genetic testing.

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 35-year-old Hispanic woman who immigrated from Mexico in her mid-20s, seen at an urban gynecology clinic and hospitals. The authors are from Intermountain Healthcare, Saint Joseph Hospital, Denver, USA. Dates of care are not given.
• Exposure: No asbestos exposure was identified. The patient denied prior known asbestos exposure. No fiber type, product or job is reported.
• Main results:
  • Pathology from the initial surgery confirmed a mature cystic teratoma. No malignant tissue was found in the pelvic washings, fallopian tube or ovary.
  • On postoperative day 28 she had fever, abdominal pain and myalgias, with a white blood cell count of 25 k/uL. CT showed two 5-cm abdominal fluid collections suggestive of abscesses.
  • At 11 weeks after her initial surgery, CT showed an increased number of solid masses with central necrosis along the liver, spleen, mesentery and pelvic inlet.
  • She was diagnosed with stage IV malignant peritoneal mesothelioma, epithelioid subtype, based on positive staining for D2-40 and CK5/6.
  • The first (omental) biopsy was positive for BAP1. The second (liver) biopsy tested negative for BAP1.
  • Tumor testing showed a tumor mutational burden of 27 mutations. Reported mutations were NF2, MLL2, ARID1A, PIK3CA, EP300, NFE2L2 and TERT.
  • A 78-gene hereditary cancer test found no clinically significant mutations, gross deletions or duplications, including for the BAP1 gene. A variant of uncertain clinical significance was identified in ATM.
  • She was treated with cisplatin and pemetrexed. Five months after the initial surgery she was admitted for a small bowel obstruction, later chose comfort care, and died 6 months after her initial procedure.
• The authors' conclusion: The authors concluded that the patient's rapid disease course was likely accelerated by expansive spread inside the abdomen, seeding of surgical trocar sites from her procedures, and multiple somatic mutations in BAP1, NF2, MLL2 and ARID1A. They concluded that gynecologic surgeons should keep a broad differential for postoperative complications in young, healthy-appearing women, as hidden cancers can present with nonspecific symptoms.
• Limitations the authors state:
  • The patient died before additional genetic testing could be done.

Topics

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

Medical terms in this study, explained in our Lexicon: Peritoneal Mesothelioma, Prognosis, BAP1, Laparotomy, Biopsy, Podoplanin (D2-40).

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• Postoperative outcomes of laparoscopic vs open cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy for treatment of peritoneal surface malignancies — G. Passot, N. Bakrin, et al. (2014)
• A new policy regarding ovarian resection in young women treated for peritoneal carcinomatosis — D. Elias, E. Duchalais, et al. (2013)
• Dextrose-Containing Carrier Solution for Hyperthermic Intraperitoneal Chemotherapy: Increased Intraoperative Hyperglycemia and Postoperative Complications — R.J. Torphy, C. Stewart, et al. (2020)
• Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in Asian patients: 100 consecutive patients in a single institution — M.C. Teo, G.H. Tan, et al. (2013)
• A Novel Tool for Predicting Major Complications After Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy — J.M. Baumgartner, T.G. Kwong, et al. (2016)

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