A 31 year-old male was admitted to the Dept. of Surgery, SNU Hospital on October 26, 1965 complaining of abdominal distension, anorexia, indigestion, general weakness, and weight loss.
About 8 years ago, the patient noticed a fingertipsized mass which was palpable slightly below and on the right side of the umbilicus. It was free of any symptoms. However, the mass gradually enlarged to an adult fist-sized mass with the development of the above symptoms. The enlarged mass was excised on April 7, 1964 only to see a recurrence in December of the same year,when another excision was made. As the second excision was again followed by the regrowth of the mass, radiation therapy was tried in May, 1965 which brought about a slight regression of the mass, About 20 days prior to admission, abdominal distension and weight loss got aggravated.
Physical examination revealed markedly distended and tensile abdomen with shifting dulness, Palpable in :the right hypochondriac region was an aduld fist-sized, non-tender and elastic hard mass which was ill-defined and uneven surfaced. No pitting edema was present on the leg.
Laboratory data were normal except for anemia, elevated ESR, leukocytosis, neutrophilia. Ascitic fluid containded numerous RBC, many mesothelial cells and few lymphocytes.
Upon exploratory laparotomy, 1,000 cc. of hemorrhagic, viscid ascitic fluid was present in the abdominal cavity. Peritoneum, greater and lesser omentums, mesentery, and mesccolon were extensively involved with numerous, greyish white, rice to small bean-sized masses. On the diaphragmatic surface of the liver were two adult fist-sized greyish white firm masses, the surfaces of which were nodulated and 3 to 4 dilated, bluish purple vessels were traversing on them. They were attached to the parietal peritoneum by pedicles.
Microscopic findings are as follows: Cells were enlarged and some were elongated or spindle shaped and others were polygonal or round. The nuclei were enlarged, vesicular, hyperchromatic, and ovalor round with mitotic figures. The nuclear membranes were thickened with prominent nucleoli. Cytoplasm was abundant . and eosinophilic. Cell mass was mostly tubular but some showed angiomatoid or pseudoglandular pattern. Stroma and fibroblasts of the connective tissue were observed to have proliferated without cystic degeneration,. necrosis or papillary formation. Mesothelioma originates from the pericardium, pleura, and peritoneum. Pleural mesothelioma can be classified into benign, solitary tumors of fibrous nature and malignant diffuse tumors. The majority of peritoneal mesotheliomas are of the diffuse type and are associated with abdominal distension, palpable, mass, ascites, general weakness,malaise and weight loss. The tumor mass is firm and have a greyish white or greyish purple color with nodulations. Microscopic examination discloses frbrous, papillary, tubular patterns.
The tumors do not contain intracytoplasmic carminophilic droplets but extracytoplasmic mucopolysaccharide can be demonstrated. In ascitic fluid, hyaluronic acid is present. Metastasis is usually by surface extension but rarely distant metastasis by the lymphatic or hemorrhagic route is seen.
This tumor was called also as endotheliaoma, celiothelioma, endothelial carcinoma or carcinosarcoma.
Symptoms are epigastric distress, pain, anorexia, nausea, vomiting, abdominal distension and marked weight loss when advanced.
Diagnosis can be made with history, clinical symptoms, signs and course, tissue culture, biopsy with hematoxylin-eosin and special staining showing extyacytoplasmic mucopolysaccharide, demonstration of hyaluronic acid in ascites and absence of other primary tumor.
As to treatment, local excision is most effective in localized fibrous type and radioactive colloidal gold infusion into peritoneal cavity in diffuse type.
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