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Peritoneal Mesotheliomas: Clinicopathologic Features, CT Findings, and Differential Diagnosis

Ji Yeon Park1, Kyoung Won Kim1, Heon-Ju Kwon1, Mi-Suk Park2, Gui Young Kwon3, Sun-Young Jun4 and Eun Sil Yu3

1 Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Pungnap 2-dong, Songpa-ku, Seoul 138-736, South Korea.
2 Department of Radiology, Yonsei University College of Medicine, Severance Hospital, Seoul, South Korea.
3 Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea.
4 Department of Pathology, Hallym University Sacred Heart Hospital, Gyeonggi-do, South Korea.


Figure 1
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  		Fig. 1A —72-year-old woman with malignant peritoneal mesothelioma who presented with incidentally detected perihepatic masses. Axial contrast-enhanced CT scan shows low-attenuation masses in perihepatic space (arrowheads) that indent lateral and inferior aspects of right hepatic lobe.

 

Figure 2
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  		Fig. 1B —72-year-old woman with malignant peritoneal mesothelioma who presented with incidentally detected perihepatic masses. Microscopically, there was diffuse infiltration of pleomorphic epithelioid cells with frequent mitosis. On immunohistochemical staining, tumor cells are positive (brown) for calretinin, which is mesothelial cell marker (calretinin immunostain, x400). Histopathologic diagnosis was malignant peritoneal mesothelioma.

 

Figure 3
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  		Fig. 2A —43-year-old woman with malignant peritoneal mesothelioma who presented with abdominal distention. Axial contrast-enhanced CT scan shows diffuse irregular thickening (arrowheads) of parietal peritoneum up to 1.5 cm in thickness. Large amount of ascites is also noted.

 

Figure 4
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  		Fig. 2B —43-year-old woman with malignant peritoneal mesothelioma who presented with abdominal distention. At level of lower abdomen, CT scan shows multiple masses (arrowheads) involving greater omentum.

 

Figure 5
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  		Fig. 3 —55-year-old man with peritoneal carcinomatosis from stomach cancer who presented with abdominal distention. Axial contrast-enhanced CT scan shows omental cakes (long arrows), peritoneal nodules (arrowheads), and massive ascites. Peritoneal thickening is less severe, and amount of ascites is disproportionately large compared with malignant mesothelioma. Metastatic liver nodule (short arrow) is also noted.

 

Figure 6
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  		Fig. 4A —67-year-old woman with serous papillary carcinoma of peritoneum who presented with abdominal distention. Coronal contrast-enhanced CT scan shows huge omental masses (arrowheads) and large amount of ascites.

 

Figure 7
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  		Fig. 4B —67-year-old woman with serous papillary carcinoma of peritoneum who presented with abdominal distention. On photograph of gross specimen, cut surface of multiple omental masses is heterogeneous, whitish yellow with multifocal hemorrhage and necrosis

 

Figure 8
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  		Fig. 5 —75-year-old man with peritoneal lymphomatosis who presented with abdominal distention. Axial contrast-enhanced CT scan shows huge conglomerated lymphadenopathy (arrows) in mesocolon and small amount of ascites. Retroperitoneal lymphadenopathy (arrowheads) is also noted posterior to left renal vein.

 

Figure 9
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  		Fig. 6A —56-year-old man with malignant peritoneal mesothelioma that masqueraded as exophytic liver mass. Axial contrast-enhanced CT scan obtained during arterial phase shows large lobulated mass (asterisk) with heterogeneous contrast enhancement in right anterior subphrenic space invading liver. Small amount of ascites is also noted.

 

Figure 10
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  		Fig. 6B —56-year-old man with malignant peritoneal mesothelioma that masqueraded as exophytic liver mass. Axial contrast-enhanced CT scan obtained during portal venous phase also shows large lobulated mass (asterisk) with heterogeneous contrast enhancement in right anterior subphrenic space invading liver.

 

Figure 11
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  		Fig. 6C —56-year-old man with malignant peritoneal mesothelioma that masqueraded as exophytic liver mass. High-power photomicrograph shows pleomorphic epithelioid cells with frequent mitosis (H and E, x400). Tumor cells were positive for calretinin (not shown). Histopathologic diagnosis was malignant peritoneal mesothelioma.

 

Figure 12
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  		Fig. 7A —10-year-old boy with malignant peritoneal mesothelioma who presented with abdominal distention. Axial contrast-enhanced CT scan shows huge cystic lesion (asterisk) with thick-walled septa replacing right lobe of liver and extending from hepatic hilum.

 

Figure 13
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  		Fig. 7B —10-year-old boy with malignant peritoneal mesothelioma who presented with abdominal distention. Low-power photomicrograph shows several foci of solid aggregations of tiny nests of mesothelial cells in visceral peritoneum of liver. (H and E, x40)

 

Figure 14
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  		Fig. 7C —10-year-old boy with malignant peritoneal mesothelioma who presented with abdominal distention. Photomicrograph shows variably thickened fibrous cystic walls with lining mesothelial cells (H and E, x40). On electron microscopy (not shown), there were glandular arrangements of plump epithelial cells with large irregular nuclei and prominent nucleoli. Luminal surfaces of epithelial cells showed well-developed, long, and slender microvilli. Based on histopathologic and electron microscopic findings, diagnosis of malignant peritoneal mesothelioma with cystic change was made.

 

Figure 15
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  		Fig. 8A —25-year-old woman with multilocular cystic mesothelioma who presented with amenorrhea and abdominal pain. Axial contrast-enhanced CT scan shows variably sized, thick-walled, multiloculated cystic masses (arrowheads) in mid abdomen.

 

Figure 16
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  		Fig. 8B —25-year-old woman with multilocular cystic mesothelioma who presented with amenorrhea and abdominal pain. On photograph of gross specimen, multilocular cystic sticky appearance of peritoneal mass is seen. Cysts contained serous fluid.

 

Figure 17
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  		Fig. 8C —25-year-old woman with multilocular cystic mesothelioma who presented with amenorrhea and abdominal pain. Low-power photomicrograph shows multilocular cysts lined by fibrous walls of variable thicknesses (H and E, x40). Cells lining cysts were positive for cytokeratin (not shown). Histopathologic diagnosis was cystic mesothelioma.

 

Figure 18
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  		Fig. 9A —54-year-old woman with unilocular cystic mesothelioma who presented with palpable mass in right lower quadrant. Axial contrast-enhanced CT scan shows huge well-defined unilocular lesion (asterisk) displacing liver, pancreas, and duodenum.

 

Figure 19
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  		Fig. 9B —54-year-old woman with unilocular cystic mesothelioma who presented with palpable mass in right lower quadrant. Tumor cells are positive for calretinin, which is mesothelial cell marker (calretinin immunostain, x200). Histopathologic diagnosis was cystic mesothelioma.

 

Figure 20
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  		Fig. 10A —42-year-old man with cystic lymphangioma who presented with abdominal distention. Axial contrast-enhanced CT scan shows multilocular cystic mass (asterisk) in left upper abdominal cavity.

 

Figure 21
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  		Fig. 10B —42-year-old man with cystic lymphangioma who presented with abdominal distention. On photograph of gross specimen, oligolocular cystic mass is seen in peripancreatic adipose tissue. In contrast to cystic mesothelioma, which shows strong predilection for pelvis, cystic lymphangioma has no regional predilection.

 

Figure 22
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  		Fig. 11A —54-year-old woman with malignant transformation of cystic mesothelioma who presented with palpable mass in left lower quadrant. Axial contrast-enhanced CT scan shows large thin-walled cystic mass (asterisk) in left lower quadrant.

 

Figure 23
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  		Fig. 11B —54-year-old woman with malignant transformation of cystic mesothelioma who presented with palpable mass in left lower quadrant. Axial contrast-enhanced CT scan obtained 5 years after A shows large lobulated mass with both cystic and solid compartments in left lower quadrant invading retroperitoneum and posterior abdominal wall. Malignant transformation of preexisting cystic mass is suggested.

 

Figure 24
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  		Fig. 11C —54-year-old woman with malignant transformation of cystic mesothelioma who presented with palpable mass in left lower quadrant. Partial excision of mass was performed. On photograph of gross specimen, multiple omental masses and nodules without hemorrhage or necrosis are seen. Microscopically, there was diffuse infiltration of pleomorphic epithelioid cells with frequent mitosis (not shown). Histopathologic diagnosis was malignant peritoneal mesothelioma.

 

Figure 25
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  		Fig. 12A —58-year-old woman with well-differentiated papillary mesothelioma who presented with abdominal distention. Axial contrast-enhanced CT scan shows massive ascites and nodular omental infiltration. There were no significantly enlarged lymph nodes and no definite bowel wall thickening (not shown).

 

Figure 26
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  		Fig. 12B —58-year-old woman with well-differentiated papillary mesothelioma who presented with abdominal distention. Photograph of gross specimen shows multiple small nodules (orange) scattered in omentum.

 

Figure 27
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  		Fig. 12C —58-year-old woman with well-differentiated papillary mesothelioma who presented with abdominal distention. Low-power photomicrograph shows papillary growth pattern in fibrovascular core, which is lined by single layer of cuboidal epithelial cells (H and E, x40). Histopathologic diagnosis was well-differentiated papillary mesothelioma.

 

Figure 28
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  		Fig. 12D —58-year-old woman with well-differentiated papillary mesothelioma who presented with abdominal distention. On follow-up 1 year after A–C, axial contrast-enhanced CT scan shows ill-defined enhancing mass involving peritoneal surface of lower abdomen and anterior abdominal wall. Massive ascites is also noted.

 

Figure 29
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  		Fig. 13A —56-year-old woman with well-differentiated papillary mesothelioma who presented with abdominal distention. Axial contrast-enhanced CT scan shows thickened, "smudged" greater omentum (arrowheads) and massive ascites.

 

Figure 30
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  		Fig. 13B —56-year-old woman with well-differentiated papillary mesothelioma who presented with abdominal distention. On photograph of gross specimen, multiple nodules and thickening of greater omentum are seen. Histopathologic diagnosis was well-differentiated papillary mesothelioma.

 

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