Malignant peritoneal mesothelioma of the ovary
Introduction
Introduction of ovarian malignant peritoneal mesothelioma Ovarian malignant peritoneal mesothelioma is a relatively rare tumor. Although mesothelioma was reported as early as 1870, it was recognized after the 1960s. It originates from a relatively primitive precursor cell under mesothelial cells or mesothelial cells and can occur on any mesothelial epithelium covered by mesothelium. Among them, pleural mesothelioma is the most common, followed by the peritoneum, and in the pericardium and testicular sheath. Membranes are rare. Malignant peritoneal mesothelioma is a malignant tumor originating from the peritoneum. It used to be called carcinomatosis. Due to its complex and diverse tissue structure, it is very similar to the morphology of metastatic adenocarcinoma. It is difficult to diagnose in women. Patients are easily misdiagnosed as ovarian cancer. basic knowledge The proportion of illness: 0.005% Susceptible people: women Mode of infection: non-infectious Complications: intestinal obstruction
Cause
Ovarian malignant peritoneal mesothelioma
(1) Causes of the disease
In 1946, Wyers first noticed that malignant mesothelioma appeared to be associated with exposure to asbestos. In 1960, Wagnert et al. confirmed the close relationship between the occurrence of mesothelioma and exposure to asbestos dust. The proportion of patients who reported history of asbestos exposure in the future was very different. From 0% to 100%, most of the literature is 70% to 80%. Asbestos exposure includes occupational, environmental and asbestos workers' family members, the most important of which is occupation. According to statistics, shipyard workers, textile workers, pipelines The incidence of workers, welders, painters and construction workers is 300 times higher than that of the general population. The incidence of residents and asbestos workers near these mines is also significantly higher than that of ordinary people. Asbestos is a ubiquitous substance. There are 3,000 kinds of industrial uses. According to the observation of autopsy on autopsy, it is found that almost 100% of the urban population has hidden asbestos fibers in the lung tissue. The carcinogenicity of asbestos is related to the contact time, the amount of contact, and the asbestos fiber. Type, characteristics, length and sensitivity of the host. It has been observed that experimental animals inducing mesothelial hyperplasia after inhalation or infusion of asbestos fibers, atypical hyperplasia to cancer In the process of change, the three asbestos fibers have the same carcinogenicity. Human mesothelioma is mainly caused by crocidolite, followed by iron asbestos and tremolite. The physical shape is more important than chemical composition. The carcinogenic fiber is 0.5. Filaments of ~50m length are generally inhaled into the respiratory tract and then inhaled into the abdominal cavity through the diaphragm or blood flow. Asbestos filaments deposited in the tissue form a golden or brown-red length due to deposition of ferritin. Sectional or curved bodies, called asbestos bodies, which are easily identifiable in tissue sections, and some small body margins can occur in foreign body giant cell reactions. 84 cases of peritoneal mesothelioma have been observed, 54 of which have occupational asbestos exposure history And a certain amount of asbestos bodies were found in the lung tissue. It is generally believed that the greater the amount of exposure to asbestos and the longer the time, the more chances of finding peritoneal mesothelioma, from the exposure to asbestos to mesothelioma, which is less than 1 year, up to 50 years, most authors believe that there is a long incubation period, an average of 33 to 43 years, so the age of onset is more common in 50 to 70 years old, more men than women, about 2:1, which may Yes Sex in occupational asbestos exposure more reason.
The occurrence of mesothelioma may also be related to radioactive substances, viruses, heredity, individual sensitivity and chronic inflammation. The occurrence of malignant mesothelioma after radiotherapy for potted and abdominal malignant tumors has also been reported. The incubation period is often long, so The follow-up of patients who survived 10 to 20 years after radiation therapy is very meaningful. It can be seen that the occurrence of mesothelioma has many factors as other tumors.
(two) pathogenesis
Studies have found that asbestos fibers inhibit the activity of natural killer (NK) cells in vitro. Robinson (1989) believes that asbestos fibers strongly inhibit the activity of NK cells, which play an important role in anti-cancer immune surveillance, which is at least a mechanism of carcinogenesis. One.
1. Generally seen, according to the growth pattern and shape of the tumor, it can be divided into two types: diffuse type and limited type. The former is more common.
Diffuse growth characteristics are extensively affected by the peritoneum, often below the abdomen or pelvic cavity, the peritoneal viscera, the wall layer can be seen with many tumor nodules of different sizes, the nodule boundary is unclear, wide base or pedicle with different lengths, Some can be fused into larger masses (or maternal tumors), dark red or grayish white, soft or brittle, easy to fall off, and some tumors can be expressed as a large piece of armor-like thickening of the serosal surface, up to 5cm. Some organs such as liver, spleen, and pancreas are wrapped in tumors, and the intestines are adhered into a mass. The omentum is in the form of a cake. In more serious cases, the abdominal cavity is completely closed.
Localized type occurs in the upper abdomen or pelvic cavity, often forming a large mass attached to the visceral layer of the serosa, the diameter can exceed 10cm, its soft and brittle or fibrous, hard, necrotic, bleeding, surrounding tissues such as liver, spleen The pancreas, gastrointestinal tract and posterior peritoneal organs have different degrees of infiltration. The peritoneal viscera and the parietal layer also have scattered small tumor nodules. Individual confinement is a single tumor with intact capsule, which may be benign or low-grade. rarely seen.
In general, in any category, most of the uterine attachments adhere to the surrounding cancer tissue, the boundaries are unclear, postoperative gross pathology and microscopic examination, the uterus, ovary is normal size, can be atrophied after menopause, only the surface has cancer nodules, In recent years, malignant mesothelioma with or without ovarian mass expression has been reported.
2. Light microscopy Seen from histology, mesothelial cells have the characteristics of bidirectional differentiation, which can differentiate into epithelial cells, form epithelioid tumors (epithelial type), and can also differentiate into mesenchymal cells to form spindle cell tumors (sarcoma type). It can also form two kinds of tumors with mixed tissue morphology (mixed type), so it is generally divided into 3 types. According to the morphology of the cells, such as the presence or absence of heteromorphism and giant tumor cells, and the number of mitotic figures, the difference is good and malignant, but the actual In terms of the biological behavior of tumors seen clinically, there is still a possibility of malignancy.
(1) Epithelial type: Epithelial cells can be high columnar, cubic or polygonal, arranged in papillary, glandular, cord-like, flaky, etc. Typical epithelial-like cells are mildly eosinophilic and fine-grained, often There are vacuoles, enlarged nuclei, clear nuclear membrane and nucleoli, singularly distinct tumor cells, varying sizes, multi-nuclear giant cells, mitotic figures, and generally no obvious basement membrane.
(2) sarcoma type: tumor cells are fusiform, arranged in a band or snail ring, high differentiation, tumor cells are fine and long, interstitial collagen fibers and reticular fibers; low differentiation, short and thick cells, interstitial There are few or no collagen fibers and reticular fibers, and the number of mitotic figures varies.
(3) Mixed type: The above two types of structures are mixed to different extents, and transitional cells between the two are also common. According to the literature reports and the data of Peking Union Medical College Hospital, the above skin types are common (Table 1). Mixed and sarcoma types are more common in children.
3. Histochemistry, immunohistochemistry and electron microscopy
(1) Histochemical method: used for the detection of acidic and neutral mucopolysaccharides, commonly used methods are colloidal iron staining (Coll Fe), PAS staining, mucus card red staining, malignant mesothelioma can produce a large amount of hyaluronic acid (acidic Mucopolysaccharide), and the adenocarcinoma contains neutral mucopolysaccharide, which is digested with hyaluronidase and then stained with colloidal iron (Coll Fe-D). After digestion with amylase, PAS staining (PAS-D) or mucus Card red staining, a negative reaction in mesothelioma, and most positive in adenocarcinoma (Table 2), these three methods can be used for differential diagnosis of mesothelioma and adenocarcinoma, in which colloidal iron staining is more reliable.
(2) Immunohistochemistry: commonly used methods are anti-carcinoembryonic antigen antibody staining (CEA) and anti-cytokeratin antibody staining (Keratin). In most literatures, the positive rate of CEA in mesothelioma is only 15%. In adenocarcinoma, it is 86%. Keratin is mostly positive in both, CEA-negative and Keratin-positive, which is helpful for the diagnosis of mesothelioma.
(3) Electron microscopy: Ultrastructural features include dense and slender microvilli, glycogen, desmosome, basement membrane, and tension microfilaments. However, these features partially overlap with the ultrastructural features of adenocarcinoma, Warhol (1982), etc. Firstly, a quantitative study was carried out. The average microvilli length to diameter ratio (LDR) of the former was 11.9, while the latter was 5.28. There was a significant difference between the two (P<0.01). It was also found that the mesothelioma cytoplasm contained abundant tension. Microfilaments, but few or absent in adenocarcinoma, tension microfilaments and LDR are good parameters for the diagnosis of mesothelioma, and have been confirmed by later studies, domestic scholars believe that the average microvilli aspect ratio is greater than 11 or more were malignant mesothelioma, and the average microvilli aspect ratio of metastatic adenocarcinoma was <5.
Prevention
Ovarian malignant peritoneal mesothelioma prevention
It is very important to maintain a good attitude, to maintain a good mood, to have an optimistic, open-minded spirit, and to be confident in the fight against disease. Don't be afraid, only in this way can you mobilize your subjective initiative and improve your body's immune function.
Complication
Ovarian malignant peritoneal mesothelioma complications Complications, intestinal obstruction
Intestinal obstruction: The vast majority of patients die from this complication of the primary tumor.
Symptom
Ovarian malignant peritoneal mesothelioma symptoms Common symptoms Abdominal abdominal pain, ascites, lower abdominal mass, bloody ascites, loss of appetite, weight loss, thrombocytopenia, hypoglycemia
The most common symptoms are bloating, abdominal pain, ascites and abdominal mass. The vast majority of patients (90%) have serous or bloody ascites, which grow rapidly, especially in diffuse mesothelioma. There is no clear positioning of burning sensation or dull discomfort, but also severe abdominal pain, urination, exacerbation during defecation, often accompanied by systemic symptoms such as fatigue, weight loss, loss of appetite, Karakosis has analyzed 24 patients with malignant mesothelioma, bloating, The incidence of abdominal pain, abdominal mass, and wasting were 79%, 29%, 33%, and 27.3%, respectively. A small number of patients initially showed chronic intestinal obstruction. Individual tumors may produce antidiuretic hormone, growth hormone, adrenal hormone or insulin-like substance. , hypoglycemia symptoms, etc., thrombocytosis and thromboembolism are also more common.
Examine
Examination of ovarian malignant peritoneal mesothelioma
Ascites examination
Ascites is bloody or serous fibrinous, with a high specific gravity (mostly >1.020), positive for the positive test, ascites cytology, if there are a large number of atypical, atypical mesothelial cells or tumor cells have important diagnostic significance However, due to its atypical morphology, it is often not distinguishable from the hyperplastic mesothelial. The general scholars believe that it is difficult to diagnose by cytology alone. Trio1 (1984) observed 75 cases of malignant mesothelioma confirmed by autopsy. 18 cases (24%) were diagnosed, 37 cases (48%) were suspected, and the mucopolysaccharide (mainly hyaluronic acid) was contained in the tumor cells and exudate of malignant mesothelioma, which was reported to be in the exudate. Hyaluronic acid is 5 ~ 50mg / L, 66% of patients with mesothelioma, >50mg / L of 82% of patients with mesothelioma, ascites hyaluronic acid level, has a certain reference value for the diagnosis of this tumor.
2. Gastroscopy
The following signs can be seen during gastrointestinal angiography:
(1) Intestinal fistula changes due to extensive involvement of the peritoneum, such as small bowel fistula deformation, poor activity and fixation.
(2) The intestinal lumen can cause eccentric stenosis and even obstruction due to external pressure.
(3) Due to the transition of the adhesion of the tumor tissue, abnormalities in the distribution of intestinal fistula often occur.
(4) There was no obvious damage to the intestinal mucosa, and no lesions were seen in the digestive tract.
These changes are not X-ray features of malignant mesothelioma. For example, multiple intra-abdominal metastases and some lesions that invade the peritoneum can be produced. In general, X-ray examination reveals extensive compression deformation of the gastrointestinal tract. Position, abnormal alignment, etc., and mucosal folds without significant damage, should consider the possibility of primary peritoneal mesothelioma, there are a few tumors from the serosal surface directly to the intestinal mucosa, causing intestinal mucosal destruction, the formation of ulcers.
3.B-ultrasound
B-ultrasound can accurately report the ascites, large tumors in the pelvic cavity, etc., often can see the fixation of intra-abdominal intestinal fistula, irregular thickening of the intestinal wall, and abnormal echoes that suggest the implantation of tumor in the abdominal cavity, etc. When the peritoneum is invaded, the original continuous uniform peritoneal line is undulating, and there may be small spherical nodules, localized plate-like thickening or irregular mass.
4. CT examination
CT mainly manifested as ascites, irregular thickening of peritoneal adhesions and peritoneal nodules, omental and mesenteric involvement, pelvic mass, pleural involvement (pleural thickening, pleural effusion), etc., early detection of peritoneal lesions is not easy to find; when the peritoneum When the omentum and mesentery are extensively thickened and adhered, CT findings may indicate the diagnosis of the disease; but it is not easy to distinguish from ovarian cancer, gastrointestinal tumor metastasis and chronic intra-abdominal infection. CT is regularly reviewed to observe the progression and efficacy of the lesion. Often useful.
5. Serum CA125 detection
According to Simsek (1996), 7 patients with malignant peritoneal mesothelioma had elevated serum CA125 levels, averaging 308 kU/L (8-1300 kU/L), and were found to be sensitive to chemotherapy in 3 patients. CA125 decreased to normal in one patient, and CA125 continued to increase in one patient with chemotherapy failure. CA125 can also be used as an indicator to monitor treatment response.
6. Laparoscopy:
Laparoscopy can directly see the appearance of the abdominal cavity, the location and extent of the tumor, and biopsy in the dirty, parietal peritoneum and omentum. It is a reliable preoperative diagnosis, especially for tuberculous peritonitis, liver. In the differential diagnosis of sclerosing ascites, the biopsy tissue can be used to confirm the cancerous or non-cancerous disease by sending a pathological examination. For example, if the biopsy tissue is small, the pathology is often difficult to be a metastatic cancer or mesothelioma, but both require surgical treatment. Does not affect the processing.
Diagnosis
Diagnosis and diagnosis of ovarian malignant peritoneal mesothelioma
Diagnostic criteria
According to clinical manifestations, X-ray and ultrasound examinations can provide the possibility of tumor presence, but the diagnosis depends on laparoscopy, laparotomy and pathology. When histology is atypical, especially the morphology of epithelial mesothelioma is similar. In metastatic adenocarcinoma, when EPSPC is dominant in mesothelial cells, traditional light microscopy is sometimes difficult to distinguish. It is necessary to combine histochemistry, immunohistochemistry and electron microscopy observation to make a more accurate diagnosis.
Differential diagnosis
Tuberculous peritonitis
Tuberculous peritonitis is mostly under 40 years old, often with fever, night sweats, increased erythrocyte sedimentation rate and other symptoms of tuberculosis, 50% of the abdomen has a "skull face", ascites is mostly yellowish, sometimes bloody, specific gravity 1.016 ~ 1.020, cytology The smear showed leukocytosis, mainly monocytes, and 5% to 10% of acid-fast staining could find tuberculosis. The positive rate of tuberculosis culture of ascites was 40%, and anti-tuberculosis treatment was effective.
2. Insulinoma
Due to paroxysmal convulsions, coma is easily misdiagnosed as hypoglycemia coma, insulinoma, malignant mesothelioma caused by hypoglycemia coma may be caused by excessive consumption of carbohydrates in the metabolic process after the tumor grows to a certain extent, or It is related to the synthesis of an insulin-like polypeptide by this tumor.
3. Cirrhosis ascites
The abdominal pain, ascites and digestive tract dysfunction of the tumor are similar to the clinical manifestations of cirrhosis. If the patient has a history of hepatitis, it is easily misdiagnosed as cirrhosis ascites.
4. Abdominal metastatic tumor
Abdominal primary tumors are rare. First of all, we should pay attention to metastatic tumors from the digestive tract, breast, lung, ovary, etc. Preoperative CT and X-ray examinations are helpful for differential diagnosis, and are carefully explored during surgery, except for concealed The original spot.
5. Extraovarian peritoneal serous papillary carcinoma (EPSPC)
The tumor originates on the surface of the peritoneum. The bilateral ovaries are normal or only slightly infiltrated. The histological morphology resembles ovarian serous papillary carcinoma. The preoperative misdiagnosis rate is almost 100%. It is necessary to identify EPSPC, ovarian cancer or mesothelioma. After laparotomy and pathological examination, the final diagnosis was made in conjunction with the EPSPC diagnostic criteria of the US GOG.
