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Multicystic Mesothelioma of the Peritoneum

¹ Department of Radiology, Keller Army Community Hospital, West Point, NY 10996-1197; Division of Radiologic Sciences, Department of Radiology, Wake Forest University School of Medicine, Medical Center Blvd., Winston-Salem, NC 27157-1088; and Departments of Radiology and Nuclear Medicine, Uniformed Services University of Health Sciences, 4301 Jones Bridge Rd., Bethesda, MD 20814-4799.
² Department of Radiology, Madigan Army Medical Center, Bldg. 9040, Fitzsimmons Dr., Tacoma, WA 98431-0001.
³ Department of Pathology, Madigan Army Medical Center, Tacoma, WA 98431-0001.

Received March 8, 2001; accepted after revision April 13, 2001.

 
Address correspondence to L. T. Bui-Mansfield at the West Point address.

From the radiologic—pathologic correlation conferences of Madigan Army Medical Center, Tacoma, WA 98431-0001.

The opinions and assertions contained herein are those of the authors and should not be construed as official or as representing the opinions of the Department of the Army or the Department of Defense.

Introduction

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During a pelvic examination, a 44-year-old woman was found to have an abdominal mass. Pelvic sonography revealed a complex multiseptate cystic mass (Fig. 1A). MR imaging showed a 15 x 9 x 7 cm mass arising from the uterine fundus; on T2-weighted images, the mass exhibited intermediate and high signal intensity. Fine septations were seen in the cystic component of the mass (Fig. 1B). The patient underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy. The hysterectomy specimen showed an irregular multilocular cystic mass attached to the uterine fundus (Fig. 1C). Microscopic examinations found multiple mesothelium-lined cysts surrounded by a fibrovascular stroma with adenomatoid changes (Fig. 1D). The pathologic diagnosis was multicystic mesothelioma of the peritoneum.

View larger version (131K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A. —Multicystic mesothelioma of peritoneum in 44-year-old woman. Pelvic sonogram shows mixed solid and complex multilocular cystic mass. Fine septations are seen within cystic component.

View larger version (129K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B. —Multicystic mesothelioma of peritoneum in 44-year-old woman. Axial T2-weighted MR image shows complex cystic mass (arrows) adhering to uterine fundus. Fine septations are visible in cystic component.

View larger version (154K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1C. —Multicystic mesothelioma of peritoneum in 44-year-old woman. Photograph of hysterectomy specimen shows irregular, multilocular cystic mass (M) attached to uterine fundus (U).

View larger version (219K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1D. —Multicystic mesothelioma of peritoneum in 44-year-old woman. Photomicrograph of specimen shown in C shows multiple mesothelium-lined cysts surrounded by fibrovascular stroma with adenomatoid changes. (H and E, x10)

Mesotheliomas are mesenchymal neoplasms originating in the serous lining of the pleura, pericardium, or peritoneum. Multicystic mesothelioma of the peritoneum is an intermediate form of mesothelioma: the severity of the disorder is greater than that of the localized, benign adenomatoid mesothelioma but is less than that of the highly lethal form of diffuse epithelial mesotheliomas [1]. Multicystic mesothelioma occurs predominantly (84% of cases) in young or middle-aged women (mean age, 37 years 10 months) [1, 2]. The tumor chiefly affects the pelvic peritoneum, particularly the uterus, cul-de-sac, bladder, and rectum, growing along the serosa as multiple translucent fluid-filled cysts. Multicystic mesothelioma is made up of mesothelium-lined cysts embedded in fibrovascular stroma. The mesothelial cells are typically flattened or cuboidal. In one third of patients, adenomatoid change or squamous metaplasia of the mesothelium is found [1]. Unlike the malignant form of mesothelioma, multicystic mesothelioma has no association with asbestos exposure [1]. The most common presenting symptoms are abdominal pain (46% of patients) and abdominal mass (29% of patients) [2]. In 18% of patients, the tumor is an incidental finding [2].

On sonography, multicystic mesothelioma appears as a multiseptate cystic mass [3]. Typically, CT reveals a well-defined, noncalcified multilocular cystic mass [2], although a case of calcification in a benign cystic peritoneal mesothelioma has been reported [4]. MR imaging shows well-defined lesions that are hypointense on T1-weighted images and have intermediate signal intensity on T2-weighted images, isointense to urine. This finding correlates with the clear watery fluid seen at gross pathologic examination [2].

Differential diagnoses include lymphangioma, endometriosis, ovarian cystadenoma or cystadenocarcinoma, teratoma, pseudomyxoma peritonei, necrotic leiomyoma or leiomyosarcoma, and epithelial inclusion cysts [1, 2]. Because of the rarity of multicystic mesothelioma, a correct pre-operative diagnosis is almost never rendered [1].

Multicystic mesothelioma is not chemo- or radiosensitive. No correlation exists between the extent of the tumor and the patient's survival. Treatment for localized lesions is total surgical excision, and for more extensive lesions, debulking procedures are performed.

References

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1. Weiss SW, Tavassoli FA. Multicystic mesothelioma: an analysis of pathologic findings and biologic behavior in 37 cases. Am J Surg Pathol 1988;12:737 -746[Medline]
2. O'Neil JD, Ros PR, Storm BL, Buck JL, Wilkinson EJ. Cystic mesothelioma of the peritoneum. Radiology 1989;170:333 -337[Abstract/Free Full Text]
3. Schneider JA, Zelnick EJ. Benign cystic peritoneal mesothelioma. J Clin Ultrasound 1985;13:190 -192[Medline]
4. Hasan AKH, Sinclair DJ. Case report: calcification in benign cystic peritoneal mesothelioma. Clin Radiol 1993;48:66 -67[Medline]

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