Journal of Surgical Case Reports, 2022, 12, 1–3

https://doi.org/10.1093/jscr/rjac555
Case Report

Case Report
Malignant peritoneal mesothelioma—a diagnostic
challenge
1,
Saad Abdul Razzak *, Faisal Awan2 and Salman Ahmed1
1 General Surgery Department, St. Luke’s General Hospital, Kilkenny, Ireland
2 St Luke’s General Hospital, Kilkenny, Ireland
*Correspondence address. General Surgery Department, St. Luke’s General Hospital, Freshford Road Kilkenny, Ireland.
Tel: (+353)-0899619415; E-mail: [email protected]

Abstract
Malignant peritoneal mesothelioma is a rare cancer originating primarily from the peritoneum with a poor prognosis and non-specific
clinical presentation. We present a case of a 60-year-old male, retired metallurgy engineer who initially presented with shortness
of breath, lethargy, weight loss, vague abdominal pain and night sweats. Extensive workup for almost 2 months finally leads to
the diagnosis of primary malignant peritoneal mesothelioma based on immunohistochemical analysis of loss of BAP1 gene. The
patient was deemed non-suitable for surgical management and started on palliative carboplatin and pemetrexed. In conclusion,
histological diagnosis is essential for peritoneal diseases before considering it as a metastasis from other primary tumours. Furthermore,
immunohistochemical analysis and genetic profiling may also guide towards the diagnosis and possible treatment.

INTRODUCTION CT-TAP that showed multiple mesenteric implants with omental

Malignant mesothelioma can be originated from different sites caking and gross ascites. No primary tumour localization was
including the pleura, peritoneum, pericardium and tunica vagi- identified (Fig. 1a–d).
nalis of the testes. The incidence of mesothelioma in the USA is After discussion in radiology MDT, an ultrasound-guided
estimated to be 1 in 100 000 people. 85% of males are attributable omental implant biopsy was taken. Post-procedure, he developed
to occupational exposure to asbestos. High-risk occupations abdominal pain, fever and increasing CRP. Histology showed cores
include mechanics, shipyard workers, plumbers, electricians and comprising bowel walls, chronic inf lammatory infiltrates and
roofers. Insidious neoplasm with poor prognosis—long latency numerous plasma cells and mesothelial cells in serosa, but no
period of up to 40 years. Malignant peritoneal mesothelioma malignancy was seen. Repeat CT-AP reported a slight increase in
accounts for up to 15–20% of all cases of mesothelioma. Patients the volume of ascites with mild peritoneal enhancement in the
are younger at diagnosis and have a less clear association with pelvis suggesting early/mild peritonitis; however, no free air was
asbestos. identified (Fig. 2).
Due to clinical deterioration, a diagnostic laparoscopy was per-
formed, which identified haemorrhagic ascites, omental caking
CASE PRESENTATION in the pelvis, supracolic and pelvic compartments completely
A 60-year-old gentleman, a retired metallurgy engineer, presented frozen. Omental biopsies were taken, and ascites f luid was sent
himself in early September 2021 with complaints of shortness of for cytology. Ascitic f luid cytology was negative for malignant
breath, weight loss, lethargy, vague abdominal pain, distension cells, and tumour markers were normal. Workup for Tuberculo-
and night sweats for the last couple of months. He has no sig- sis was also negative. Omental tissue histology reported f lorid
nificant past medical or surgical history, a non-smoker with no mesothelial proliferation—uncertain for reactive or neoplastic
relevant family history of cancers. process. A reactive lymphoid component within the adipose tissue
On initial examination, he was pale looking, afebrile and vitally stroma was identified but no histological or immunohistochem-
stable; the abdomen was soft but distended. His initial blood ical evidence of metastatic carcinoma. For further confirmation
investigations revealed microcytic hypochromic anaemia with due to indistinct findings, samples were sent to a higher speciality
haemoglobin of 9.2 mg/dl, low serum iron, transferrin, and fer- centre, which also reported similar findings. Furthermore, BAP 1
ritin, and high CRP (187 mg/l). Further workup was started with staining was suggested, which unfortunately was not available in
gastroscopy and colonoscopy, which were normal, followed by the country; therefore, samples were sent abroad. The following

Received: October 20, 2022. Accepted: November 17, 2022

Published by Oxford University Press and JSCR Publishing Ltd. © The Author(s) 2022.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which
permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.
2 | S. Abdul Razzak et al.

Figure 1. (a) Pelvic ascites. (b) Axial section showing omental caking. (c) Axial section showing omental caking. (d) Sagittal section showing peritoneal
nodularity and ascites.

report shows atypical mesothelial proliferation with occasional CT-TAP after four cycles of chemotherapy showed a reduc-
mitosis and loss of MTAP staining and nuclear loss of BAP1, which tion in ascites, new bilateral pleural effusion and sub-centimetre
confirms the diagnosis of EPITHELIOD MESOTHELIOMA. pulmonary nodularity. He has improved significantly, therefore,
His case was discussed in mesothelioma MDT and the decision continued pemetrexed. CT-AP was recently repeated after almost
for systemic chemotherapy with carboplatin and pemetrexed was a year of initial diagnosis, which shows some disease progression
made due to his extensive nature of disease burden. but he is able to maintain his functionality.
 Malignant peritoneal mesothelioma | 3

syndrome), and TP53 (Li–Fraumeni syndrome), with a median

survival of 9 years [4]. Mesotheliomas carrying BAP1 mutations
are almost always of epithelioid variety, well-differentiated
and consistent with overall good survival. It is an attractive
therapeutic target and prognostic biomarker because it is the
most frequently mutated gene in mesothelioma [5].
With the evidence of peritoneal disease burden, metastasis
from ovarian cancer in females and from the GI tract in males is
usually considered. However, the possibility of primary malignant
peritoneal mesothelioma should not be overlooked. Therefore,
histological diagnosis with an image-guided core biopsy or prefer-
ably a laparoscopic omental or peritoneal deposit biopsy should
always be considered essential.
In this case, the importance of immunohistochemistry, espe-
cially the detection of BAP1 mutation, can be emphasized in
reaching the diagnosis of malignant peritoneal mesothelioma.
Also, its non-availability can lead to delay in the diagnosis, which
not only hinders the management but also leads to an increase
Figure 2. Increase in the amount of ascites post-ultrasound-guided in patient and family’s psychological stress. Furthermore, with a
biopsy. confirmed diagnosis of MPM, an appropriate management plan
can be made that may lead to a more conservative approach
to extensive disease burden rather than rendering patients with
DISCUSSION incomplete (R1/R2) resection which confers no additional benefit
Malignant mesothelioma can be originated from different sites on overall survival.
including the pleura, peritoneum, pericardium and tunica vagi-
nalis of the testes. The incidence of mesothelioma in the USA is
estimated to be 1 in 100 000 people in the states with no asbestos CONCLUSION
industry and 2–3 cases per 100 000 persons in states with an This case report identifies the importance of immunohistochem-
asbestos industry. The use of asbestos massively reduced through ical testing and genetic profiling in the diagnosis of primary peri-
the 1970s and was banned in the UK in 1999 and in the EU in toneal mesothelioma, especially BAP 1 mutation, and also defines
2005. High-risk occupations include mechanics, shipyard workers, the pathway for the diagnosis and management of mesothelioma.
plumbers, electricians and roofers. It is an insidious neoplasm
with a poor prognosis—a long latency period of up to 40 years.
Based on histopathology, mesothelioma can be divided into CONFLICT OF INTEREST STATEMENT
three subtypes: epithelioid—60% with the best prognosis, sarco- None declared.
matoid—20% and biphasic—20%. Malignant peritoneal mesothe-
lioma accounts for up to 15–20% of all cases of mesothelioma.
Patients are younger at diagnosis with a male to female predom- FUNDING
inance of 1:1, which may be since there is less association with None.
occupational exposure. Epithelioid represents up to 90% of cases
of MPM and has the best prognosis, 25% biphasic and sarcomatoid
extremely rare. REFERENCES
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