Call For A Slide Seminar Of African Cases

Transcription

1 Call For A Slide Seminar Of African Cases ( And Not Only ) Case 5 06/09/2017 João Fraga, Paula Serra, Catarina Cerdeira, Ana Catarina Lai, Maria Beatriz Pimentão, Rui Almeida, Helder Moreira, Bruno Fernandes, Graça Fernandes, Raquel Pina

2 Enterprise Interest Nothing to declare.

3 Clinical history 2011 IPO 2012 Refractory ascitis of unknown cause Primary Health Care CHUC Male, 39 years old Chronic alcoholism (120g / day) No history of chronic liver disease / portal hypertension Symptoms: Abdominal morning ultrasound: nausea "Moderate and vomiting volume peritoneal effusion surrounding the liver and also in the pelvic excavation." 40 years Symptoms: matinal nausea and vomiting Upper abdominal CT: "Peritoneal effusion in the upper abdomen; subperitoneal thickening of the mesentery root and densification of the great epiploon "

4 Clinical history Primary Health Care CHUC No analytical changes 43 years Symptoms: abdominal pain (1 month duration) Physical examination: bulky and painful abdomen Toraco-abdomino-pelvic CT: Massive peritoneal effusion in all quadrants of the abdomen. Densification of the large omentum. Peritoneal carcinomatosis can not be excluded. "

5 Cytology Gastroenterology - diagnostic paracentesis and peritoneal biopsy Smear (Papanicolau 200x) Histology Biopsy (HE 100x) Cell-Block (HE 100x)

6 Immunohistochemistry BerEp4 100x Cell-block EMA 100x Calretinin 100x Calretinin 100x BerEp4 100x Biopsy Caldesmon 100x Desmin 100x Ki x Ki x Differential diagnosis Reactive mesothelial proliferation Mesothelioma Metastatic disease

7 Follow-up Clinical diagnosis of "Ascites of indeterminate cause" Medicated with furosemide 40id, spironolactone 100id and alcohol cessation Clinical history review: No exposure to asbestos

8 Clinical history Regular evacuation paracentesis Primary Health Care CHUC 45 years Symptoms: abdominal pain and distension, in crescendo in the last months No analytical changes Abdominal ultrasound: "Massive peritoneal effusion in all quadrants of the abdomen, free aspect"

9 Clinical history Regular evacuation paracentesis Primary Health Care CHUC Laparoscopy: Thick, congestive peritoneum Large ascitic effusion, dispersed throughout all quadrants - aspiration of about 15L with harvest for cytological study Performed appendectomy + epiplon biopsy + parietal peritoneum biopsypsy Right iliac fossa Right hypochondrium

10 Cytology Smear (Giemsa 100x) Cell-Block (HE 100x)

11 Immunohistochemistry BerEp4 100x EMA 100x Calretinin 200x Ki-67 (12%) 200x WT1 100x Differential diagnosis Reactive mesothelial proliferation Mesothelioma Metastatic disease

12 Histology Ileocecal appendix Appendicectomy - pinkish, mat serosa HE 20x HE 200x

13 Histology Epiploon Parietal peritoneum HE 40x HE 40x Epiploon biopsy witish, homogeneous, firm tissue Parietal peritoneum biopsy - white-pinkish, homogeneous and elastic tissue

14 Immunohistochemistry Differential diagnosis Reactive mesothelial proliferation Calretinin 40x BerEp4 40x EMA 40x Well-differentiated papillary mesothelioma Diffuse malignant peritoneal mesothelioma CK 5,6 40x p53 200x Desmin 200x Metastatic disease

15 Diagnosis Diffuse malignant peritoneal mesothelioma, epithelioid, with tubulo-papillary pattern, involving serosa and subserosa of the ileo-cecal appendix, mesoappendix, epiploon and peritoneum Follow-up Patient proposed for intraperitoneal chemotherapy

16 Rare neoplasia and difficult to diagnosis Nonspecific clinical and radiological presentation Diffuse malignant peritoneal mesothelioma Late diagnosis Uncertain biological behavior 75% years old Woman < Man Main risk factor: exposure to asbestos Previous contact history in 50% of cases 65%-70% 1-2% Cytology of ascitic effusion Sensibility 25% Peritoneal biopsy CT / laparoscopy Morphology: Epithelioid / Sarcomatoid / Mixed (50-75%) (5-20%) (15-40%) Better prognosis Gold standard 30% 1-2%

17 Thank You