An Unusual Case of Ascites: Pitfalls in Diagnosis of Malignant Peritoneal Mesothelioma

Malignant peritoneal mesothelioma

“…Factors contributing to delayed diagnosis include the rarity of this entity, the long latent period, and the nonspecific features of the disease, the difficulty in distinction between it and peritoneal metastatic adenocarcinoma, in addition to the technical difficulties in establishing the definite diagnosis [6,23]. Cytology of the ascitic fluid obtained by abdominal paracentesis or laparocentesis usually reveals an exudative process, and often does not result in a diagnosis as happened with 2 of our patients.…”

“…Although the disease incidence was low in the past, it is now increasing in Australia and Britain and a higher incidence can be anticipated in 2010-2020 because of the long latency (15-50 years) of this neoplasm, and due to maximal asbestos exposure between 1960 and 1970 [6,18]. On the other hand, the incidence is decreasing in USA, Canada and Netherlands, reflecting peak asbestos use between 1930 and 1960 [6,18]. It has been suggested that mesothelioma in insulation workers seems to be situated in the peritoneum more often than in the pleura [19].…”

“…The clinical presentations of MPM are nonspecific and can be categorized as ''painpredominant'' or ''ascites-predominant'' clinical type [23]. Patients usually presents with poorly localized abdominal pain, abdominal distension, constitutional symptoms of lethargy, malaise and anorexia and clinical syndrome of debilitating ascites [6]. Occasionally, the initial presentation may be weight loss, palpable abdominal mass, dysphagia, bowel obstruction, a new onset hernia, deep vein thrombosis, arterial occlusion, or even a fever of unknown origin [6,8,[23][24][25][26].…”

“…We believe that laparoscopy should be the first line diagnostic tool. Progression to laparotomy is indicated where diagnosis is not apparent on laparoscopy [6].…”

“…Miller and Wynn in 1908 were the first to describe mesothelioma stemming from the peritoneum [3]. Malignant peritoneal mesothelioma (MPM) is a relatively rare neoplasm of the abdominal and pelvic peritoneum, representing approximately 15% of all mesotheliomas, but this figure varies in different studies from 3 to 50% [4][5][6]. Australia has one of the highest annual rates of mesothelioma worldwide, ranging from 15.8-28.9 per million aged 20 years and older [6], while the annual incidence in the US is much less at about 2.2 cases per million populations [5].…”