Korean J Gastroenterol.  2019 Oct;74(4):232-238. 10.4166/kjg.2019.74.4.232.

Primary Malignant Mesothelioma of the Peritoneum Mistaken for Peritoneal Tuberculosis due to Elevated Cancer Antigen 125

• Oh JH
• Oh MJ

• KMID: 2460989
• DOI: http://doi.org/10.4166/kjg.2019.74.4.232

Abstract

A differential diagnosis of ascites is always challenging for physicians. Peritoneal tuberculosis is particularly difficult to distinguish from peritoneal carcinomatosis because of the similarities in clinical manifestations and laboratory results. Although the definitive diagnostic method for ascites is to take a biopsy of the involved tissues through laparoscopy or laparotomy, there are many limitations in performing biopsies in clinical practice. For this reason, physicians have attempted to find surrogate markers that can substitute for a biopsy as a confirmative diagnostic method for ascites. CA 125, which is known as a tumor marker for gynecological malignancies, has been reported to be a biochemical indicator for peritoneal tuberculosis. On the other hand, the sensitivity of serum CA 125 is low, and CA 125 may be elevated due to other benign or malignant conditions. This paper reports the case of a 66-year-old male who had a moderate amount of ascites and complained of dyspepsia and a febrile sensation. His abdominal CT scans revealed a conglomerated mass, diffuse omental infiltration, and peritoneal wall thickening. Initially, peritoneal tuberculosis was suspected due to the clinical symptoms, CT findings, and high serum CA 125 levels, but non-specific malignant cells were detected on cytology of the ascitic fluid. Finally, he was diagnosed with primary malignant peritoneal mesothelioma after undergoing a laparoscopic biopsy.

Keyword

Ascites; CA-125 antigen; Mesothelioma; Peritonitis, tuberculous

MeSH Terms

Aged
Ascites
Ascitic Fluid
Biomarkers
Biopsy
CA-125 Antigen
Carcinoma
Diagnosis, Differential
Dyspepsia
Hand
Humans
Laparoscopy
Laparotomy
Male
Mesothelioma*
Methods
Peritoneum*
Peritonitis, Tuberculous*
Sensation
Tomography, X-Ray Computed
Biomarkers
CA-125 Antigen

Figure

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  Fig. 1 Chest X-ray and simple abdomen scan images. (A) The chest X-ray shows increased bronchovascular markings in the right lower lung filed, but no active lung disease and pleural effusion. (B) The centralized bowel gases are noted due to massive ascites in the simple abdomen erect view.

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  Fig. 2 Contrast-enhanced computed tomography images of the abdomen show a 4.4×5.5 cm conglomerated mass (yellow arrows) among the portal vein, pancreas neck, and liver. Diffuse omental infiltration, a moderate amount of ascites and peritoneal thickening are also revealed.

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  Fig. 3 Aspiration of ascites shows suspicious malignant cells, which were finally revealed as atypical mesothelial cells (ThinPrep 2000 System; Cytyc Corp., Marlborough, MA, USA) (Papanicolaou stain, ×400).

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  Fig. 4 Gross photographs during laparoscopic biopsy reveal a large amount of ascites and multiple whitish patch nodules within the whole peritoneum, omentum, and bowel walls.

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  Fig. 5 Histology specimen shows malignant mesothelial cells, epitheloid type (A: H&E, ×100). Immunohistochemical staining of the specimens is reactive for cytokeratin and cytokeratin-7 and focally positive for calretinin, confirming the diagnosis of malignant peritoneal mesothelioma (B: cytokeratin, ×100; C: cytokeratin-7, ×200; D: calretinin, ×100).

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