Malignant mesothelioma (MM) is an aggressive cancer that has been closely linked to asbestos exposure. Initially recognized as an occupational cancer in male workers, MM was later found to occur in their family members as well. We report the case of an 89-year-old female who presented with abdominal distention, pain, and findings consistent with malignant ascites. Family history was significant for fatal mesothelioma in her husband of 40 years, who was a worker at a tile factory. The diagnosis of MM was confirmed on pathologic examination of the omental core biopsy.
MM is an aggressive tumor arising from the mesothelial or submesothelial cells of the pleura, peritoneum, or pericardium. It has been recognized as an occupational cancer that is closely related to industrial asbestos exposure. Even though the latter was either restricted or forbidden many years ago, new cases of mesothelioma continue to appear because of the long latency of the disease. This has resulted in an increasing incidence of MM worldwide, a situation that is expected to continue for another 5 to 15 years [
An 89-year-old female was admitted to our hospital because of new onset abdominal pain and distention. Her symptoms had been progressing over the preceding two weeks and were associated with lower extremity edema, loss of appetite, and urinary urge incontinence. Review of systems was negative for any change in bowel habits, vaginal bleeding, or weight loss. She had a history of postpolio syndrome, hypertension, arthritis, asthma, and glaucoma. There was no history of smoking or occupational exposure to asbestos or other carcinogens. Family history was significant for colon cancer in her brother and two paternal uncles; however, the patient herself had never undergone a screening colonoscopy. Additionally, the patient’s husband of 40 years had died of mesothelioma 3 years earlier. Positive findings on physical examination included pallor, a distended abdomen, paraplegia, and 1+ pitting edema in lower extremities bilaterally. Laboratory workup revealed low albumin (3.1 g/dL; normal 3.4–5.2 g/dL), mild normocytic anemia (hemoglobin 11.8 g/dL; normal 12–15.3 g/dL), and mild thrombocytosis (platelets 552 k/mm cu; normal 150–450 k/mm cu). Computed tomography (CT) of the chest, abdomen, and pelvis with contrast was done; this showed moderate to severe ascites, minimal nodularity in the peritoneal cavity suspicious for malignancy, and prominent adnexal tissues on both sides of the pelvis (Figure
CT of the chest shows right-sided pleural effusion (a) and calcified pleural plaques in the left hemithorax (b).
CT scan of the abdomen and pelvis shows ascites, nodularity in the peritoneal cavity (a), and prominent adnexal tissues (b).
Patient underwent paracentesis twice throughout her stay, for symptomatic relief. The ascitic fluid showed few atypical cells with large nuclei and prominent nucleoli. Immunohistochemistry was positive for calretinin and negative for carcinoembryonic antigen (CEA), Wilms’ tumor 1 antigen (WT-1), estrogen receptor (ER), progesterone receptor (PR), and CD-15; these findings were consistent with reactive mesothelial cells as well as peritoneal mesothelioma. The patient initially did not wish to pursue any invasive diagnostic workup or treatment. However, she later agreed to an ultrasound-guided biopsy during placement of a palliative peritoneal catheter system for the management of recurrent ascites. Pathologic exam of the omental core biopsy revealed well-differentiated papillary mesothelioma of epithelioid type (Figure
Hematoxylin and eosin (H&E) stain ((a) 5x magnification; (b) 20x magnification) showing a proliferation of abnormal mesothelial cells with moderate cellular atypia present in a papillary configuration.
Asbestos is a naturally occurring fiber that had a widespread industrial use for decades, dating back to 1858. In the early 1900s, researchers noticed a higher rate of lung disease and death in asbestos mining towns. The first convincing evidence of a link between MM and asbestos exposure was in 1960 by Wagner et al. [
There has been an increasing body of evidence in the literature supporting the relation between MM and household exposure, with the earliest reports by Anderson in 1982 among amosite workers in Paterson, New Jersey [
MM has a prevalence of 1-2 per million per year [
Patients with MM often present with nonspecific complaints; pleural MM frequently manifests as dyspnea and pleural pain, whereas peritoneal MM has the early symptoms of distention due to ascites, and abdominal pain. This makes MM a challenging diagnosis to establish, with a delay of up to six months prior to diagnosis [
Cytologic analysis of the pleural or ascitic fluid may be diagnostic of MM in 33 to 84 percent of the cases [
Calretinin immunohistochemical stain (5x magnification) is positive in mesothelial cells.
MM has a poor prognosis, with an estimated median survival ranging from 4 to 12 months [
MM is an aggressive tumor that has been closely related to occupational asbestos exposure. Household exposure of wives of workers may increase the risk of developing MM, and a high index of suspicion is warranted in such cases due to rarity of the disease. Clinical presentation is often nonspecific, with late detection being a common problem and ultimately contributing to the poor overall prognosis. Treatment modalities vary from combination of surgery and chemotherapy to palliative debulking.
The authors declare that there is no conflict of interests regarding the publication of this paper.