【Overview】
Peritoneal malignant mesothelioma (malignant peritoneal mesothelioma), also known as primary peritoneal mesothelioma, is originated in the peritoneal epithelium and mesothelial tissue tumors. Is a rare disease, but the reported cases has increased in recent years. Such tumors can occur in the pleura, peritoneum and pericardium: about 65% occurred in pleura, 25% occur in the peritoneum, 10% occurred in the pericardium.
【Etiology and pathogenesis 】
Asbestos dust for the pathogenic substances to the pathogenicity of crocidolite strong, followed by amosite and chrysotile asbestos. The disease mostly occurs in asbestos workers exposed to asbestos dust in the environment may also sick. Average time from exposure to onset of 35 to 40 years, sometimes only a few months and the incidence of exposure to the report, the incidence peak after 45 years in contact with.
Asbestos fibers enter the body through the respiratory tract, the peritoneal diaphragmatic lymphatic network reach can also enter the body through the intestine, but not fed to animals caused by asbestos disease.
The patient's respiratory system could be detected asbestos lung, including pulmonary fibrosis, pleural plaques and asbestos bodies transparent protein. 1 / 3 of patients with peritoneal mesothelioma peritoneal asbestos fibers can be detected. Animal experiments into the pleural or peritoneal mesothelioma, asbestos can produce.
30% of the cases no history of exposure to asbestos, so that there may be other than asbestos outside factor. Experimental study found that asbestos fibers can produce a similar nature mesothelioma. In the case of non-occupational exposure history, genetic factors may also be one of the causes of morbidity.
【Pathology】
See generally difficult to distinguish from metastasis. Often invaded the parietal and visceral peritoneum, but also invasion and local lymph nodes. 50% had visceral metastasis, but no clinical symptoms.
Diversity of histological lesions, but little more individual cells or degeneration of mitosis. Epithelial component accounted for 70%, epithelial type: tubular, papillary, flakes, flake or crack like solid nests; fibrous and sarcomatoid mesothelioma: stroma was fibrous tumor-like and spindle cell-like; mixed sex: Many mesothelioma simultaneously in a tumor epithelial and stromal components. If PAS staining and hyaluronic acid staining, but also proved to be mesothelioma.
【Diagnostic points】
Clinical manifestations
More common in men, and occupation, more than 60 years after the onset, juvenile onset who has also been reported. Abdominal pain, abdominal distension, ascites and abdominal mass are common symptoms and signs.
(1) abdominal pain: is the most common symptoms of peritoneal mesothelioma, the performance of persistent pain, pain, cramps can also paroxysmal or sudden pain, pain is usually located on the abdomen and right upper quadrant, can be abdominal symptoms caused by the following clinically misdiagnosed as ectopic pregnancy or pelvic tumors reported. The occurrence and parietal peritoneum and abdominal pain are violated, cancer and gastrointestinal tract obstruction caused by adhesions and pelvic organs, organ torsion and massive ascites, abdominal mass produce mass effect and other factors. The course of nature and the location of abdominal pain can be changed.
(2) abdominal distension: the ascites, abdominal mass, and secondary dyspepsia, intestinal obstruction and other factors, patients can have varying degrees of abdominal distention. Severe symptoms can affect eating, even breathing difficulties.
(3) ascites: approximately 90% of patients with peritoneal mesothelioma absence of ascites, and the rapid growth of a considerable number of patients with ascites and ascites drainage or bloody for the yellow viscous liquid, the tumor cells and the secretion of hyaluronic acid with the active function related.
(4) abdominal mass: a common peritoneal mesothelioma, one of the clinical manifestations, some patients is due to the treatment of abdominal mass. Peritoneal mesothelioma abdominal mass for single, also for the multiple, the largest are up to 20 cm × 30 cm, the texture more rigid or hard, nodular surface, located in the greater omentum, mesenteric serosal surface mass can move in the physical examination, abdominal mass may have tenderness. Mass in the pelvic or rectal examination can be found in triple diagnosis, associated with massive ascites drainage of ascites in patients after abdominal blocks a clearer understanding of the situation. Detailed physical examination can be a preliminary understanding of abdominal mass in the abdominal wall, substantial organ, the first visit to the clinic to provide information.
A small number of patients may also have loss of appetite, nausea, vomiting, diarrhea or constipation, urinary tract irritation, menstrual changes and fatigue, fever, weight loss, anemia, individual patients have low blood sugar, diffuse abdominal ossification and other clinical manifestations. When combined with other parts of the patient or peritoneal mesothelioma, mesothelioma metastasis to other organs or complications, can occur associated with clinical manifestations.
Laboratory
The general examination no special laboratory findings. Check for leaking ascites fluid, can also bloody, hyaluronic acid increased significantly, the diagnosis of help. But many at the middle level, and difficult to identify metastases.
Imaging
1. X-ray examination 50% of patients under X-ray signs of asbestosis. Bowel gastrointestinal imaging often show was over, or narrow, or even the performance of intestinal obstruction.
2. Ultrasound and CT examination can be found in ultrasound and CT examination of thin sheet mass, typical of those seen extensive irregular thickening of the peritoneal omentum involvement, adhesion formation pie abdominal mass, mesenteric density increased, adhesion formation mass star, may have varying degrees of ascites. B ultrasound-guided biopsy, obtain tissue cytology.
Other tests
1. Laparoscopy Laparoscopic peritoneal surface covered with visible nodules and plaques. Biopsy and pathological confirm the diagnosis.
2. Laparotomy desirable living tissue, can also detect whether the metastatic tumor, whether the primary tumor.
Differential Diagnosis
1. Malignant mesothelioma of tuberculous peritonitis and tuberculous peritonitis in the differential diagnosis difficult. In general, the majority of tuberculous peritonitis in middle-aged, clinically addition to abdominal pain, abdominal distension, ascites and other abdominal mass, fever is a common clinical manifestations. PPD-positive, ESR faster support the diagnosis of tuberculous peritonitis. Ascites with effusion as much, mainly monocytes, ascites culture that has a diagnosis of Mycobacterium tuberculosis. Highly suspected cases of tuberculous peritonitis down in close observation of effective anti-TB treatment, ineffective treatment difficult to identify cases, should seek early laparoscopy or surgical exploration, is not difficult to distinguish between pathological.
2. Peritoneal metastatic peritoneal metastatic tumors often from cancer, ovarian cancer, pancreatic cancer, liver cancer and colon cancer. When the primary clinical manifestations of occult cancer, the identification more difficult. Fecal occult blood and the need to repeatedly check the help of digestive endoscopy, gastrointestinal imaging, abdominal pelvic ultrasound and CT scan, blood sugar, AFP and other tumor antigens, and even laparoscopy to find the primary tumor. Difficult to distinguish when the desirability of pathology, in particular, immunohistochemistry or electron microscope.
3. Other primary malignant tumors in the peritoneal peritoneal serous borderline tumors, have called primary peritoneal papillary tumors and low grade peritoneal serous malignant small papillomatosis is a rare primary peritoneal lesions. Often in women, more than 40 years of age, the main symptoms are abdominal or pelvic pain. Symptoms of chronic inflammation, intestinal adhesion, or even amenorrhea. Pathology can identify with peritoneal mesothelioma, the disease prognosis is good.
Other primary tumors in the peritoneal adenocarcinoma, fibrosarcoma, liposarcoma, etc., is very rare. Can not be clinically distinguished from peritoneal mesothelioma. If the comprehensive examination has not found other parts of the primary tumor lesions, pathological examination also supported it as cancer, sarcoma, the diagnosis was established, many of these cases was confirmed in the autopsy.
【Overview】 Treatment
Drug treatment
Peritoneal mesothelioma, chemotherapy is currently considered moderately sensitive to chemotherapy is commonly used drugs are: doxorubicin, cisplatin, vincristine, thiotepa, fluorouracil, cyclophosphamide, mitomycin, of which doxorubicin the efficacy of the most positive elements. Articular injection of chemotherapy drugs in recent years advocated that the injection cavity has a high local drug concentration, systemic adverse reactions and so on. Surgical resection for patients who can not be taken as surgical tumor reduction surgery to remove the tumor, plus radiation therapy and intravitreal injection of doxorubicin and cisplatin achieved a certain effect, but more needs to be seen.
Surgery
Surgery, including tumor resection, palliative resection. Of the tumor smaller, more limited lesions, should be complete resection of the tumor and the affected organs; if the lesion is more extensive for resection of the primary tumor should be. A wide range of diseases, severe, has resulted in intestinal obstruction, surgical resection can not, palliative surgery can be considered to alleviate the patient's clinical symptoms.
Therapy
Radiation therapy including external radiation and internal radiation, can be used as 60Co or 186kV X ray radiation source, for incomplete resection or unresectable cases, Ke Yi decided to whole abdominal irradiation lesions or local irradiation.
