Mucin stratification in pseudomyxoma peritonei: a pathognomonic ultrasonographic sign

Incidental diagnosis of pseudomyxoma peritonei by laparoscopy: a rare case from Syria

Pseudomyxoma peritonei (PMP) is a rare malignancy of the abdomen, which is usually described as a gelatinous peritoneal fluid. A 33-year-old man came to the ER complaining of recurring abdominal pain with abdominal distention for the past 3 months. Abdominal ultrasound revealed moderate amount of turbulent ascitic fluid with septations, in addition to a mass with irregular margins consisting of liquid and cysts. Abdomen and pelvis computed tomography scan showed free abdominal fluid. A decision was made for abdominal diagnostic laparoscopy with biopsies from the peritoneum, mesenteries and the gelatinous fluid. We could not investigate all the abdominal cavities and appendix due to the presence of severe adhesions and tuberculosis suspension. The pathology report indicated PMP. The patient was referred to an oncologist for chemotherapy consultation. The diagnosis can be challenging, as the symptoms and signs vary from patient to another; most cases may be asymptomatic and discovered incidentally during laparoscopy.

Peritoneal disease: key imaging findings that help in the differential diagnosis

The peritoneum is a unique serosal membrane, which can be the site of primary tumors and, more commonly, secondary pathologic processes. Peritoneal carcinomatosis is the most common malignant condition to affect the peritoneal cavity, and the radiologist plays an important role in making the diagnosis and assessing the extent of disease, especially in sites that may hinder surgery. In this review, we address the role of the radiologist in the setting of peritoneal pathology, focusing on peritoneal carcinomatosis as this is the predominant malignant process, followed by revising typical imaging findings that can guide the differential diagnosis.We review the most frequent primary and secondary peritoneal tumor and tumor-like lesions, proposing a systemic approach based on clinical history and morphological appearance, namely distinguishing predominantly cystic from solid lesions, both solitary and multiple.

Pseudomyxoma peritonei originating from intestinal duplication: A case report and review of the literature

BACKGROUND

Pseudomyxoma peritonei (PMP) is a rare mucinous neoplasm with a relatively low incidence of 1 to 2 per million individuals. It is typically characterized by a type of gelatinous ascites named “jelly belly”. Most cases of PMP occur in association with ruptured primary mucinous tumors of the appendix (90%). Periodically, PMP can originate from mucinous carcinomas at other sites, including the colorectum, gallbladder, and pancreas. However, unusual origin can occur, as noted in this case report.

CASE SUMMARY

A 52-year-old woman had an unusual derivation of PMP from intestinal duplication. The patient complained of abdominal distension and increasing abdominal girth. Abdominal contrast-enhanced computed tomography showed a mass in the greater omentum located on the left side of the abdomen, likely to be a cystic mass of peritoneal origin. A PMP diagnosis was presumed based on the specific signs of the mass with flocculent and stripe-like echoes in ultrasound images. Ultrasound-guided percutaneous aspiration suggested a high likelihood of PMP. Once the PMP diagnosis was recognized, identification of the origin of the primary tumor was indicated. Thus, an exploratory laparoscopy was performed. In the absence of a primary tumor of appendix origin, the diagnosis of a low-grade mucinous neoplasm of intestinal duplication origin was finally confirmed by histopathology.

CONCLUSION

PMP is secondary to mucinous carcinomas of the appendix mostly. This case resulted from an unusual derivation from intestinal duplication.

Female patients with pseudomyxoma peritonei: a single-institution clinicopathologic study of 35 cases

PURPOSE

To explore clinicopathologic/prognostic aspects of pseudomyxoma peritonei (PMP).

METHODS

We reviewed records of 35 female patients with PMP treated at a single institution.

RESULTS

Patients' median age was 57.0 years (range 35.0-71.0 years). Their median pre-surgery level of carbohydrate antigen 19-9 (CA-199) was 80.95 U/ml (range 0.00-1,562.10 U/ml); of carbohydrate antigen 12-5 (CA-125), 44.00 U/ml (range 0.90-231.20 U/ml); and of carcinoembryonic antigen (CEA), 17.20 ng/ml (range 2.04-211.60 ng/ml). Of the 35 patients, 23 (65.7 %) underwent cytoreductive surgery (CRS) by gynecological oncologists and 12 (34.3 %) underwent non-CRS surgeries by general gynecologists or surgeons, including one patient who refused surgical treatment beyond a diagnostic laparoscopy. After surgery, 18 patients (51.4 %) had residual lesions, 11 (31.4 %) had complete lesion removal and 6 (17.1 %)had insufficient information on residual lesion; 21 (60.0 %) had appendiceal-based tumors and 12 (34.3 %) had ovarian-based tumors. Median follow-up time was 37 months (range 1-148 months), during which 28 patients (80.0 %) had relapsed. By the end of the study, 12 patients (34.3 %) died of PMP, 16 (45.7 %) survived with disease, and 7 (20 %) survived without disease. Median progress-free survival (PFS) was 12 months (range 0.5-114.0 months). Median overall survival time was 42 months (range 5-150 months). Ovarian tumor origin, post-surgery residual lesions, preoperative CA199 > 258.9 U/ml and CA125 > 70.6 U/ml were independent predictors of PFS.

CONCLUSIONS

PMP is rare in women, and has a poor long-term survival rate. Multi-center cooperation to gather more cases is needed to explore its behavior and proper treatment.