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  • • Most tumors affecting the peritoneum are secondary implants from intraperitoneal cancers (ovarian, gastric, pancreatic, etc)

    • Primary peritoneal tumors are derived from the mesodermal lining of the peritoneum

    • Patients usually present with advanced stages of disease

    • History of asbestos exposure in the case of malignant mesothelioma

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Epidemiology

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  • • The most common peritoneal neoplasms include peritoneal mesothelioma and pseudomyxoma peritonei

    • Malignant mesothelioma occurs most commonly in men, with a long latent period (averaging 40 years) after prolonged asbestos exposure

    • Pleural malignant mesotheliomas outnumber peritoneal by 3:1

    • Pseudomyxoma peritonei is caused by a low-grade mucinous cystadenocarcinoma of the appendix or ovary that secretes large amounts of mucus-containing epithelial cells

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Symptoms and Signs

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  • • Weight loss

    • Crampy abdominal pain

    • Large abdominal mass or distention due to ascites

    • Frequently intermittent or chronic small bowel obstruction

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Laboratory Findings

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  • • Ascites cytologic studies for peritoneal mesothelioma rarely positive

    • Ascites cytologic studies for pseudomyxoma peritonei may demonstrate diagnostic mucus-containing epithelial cells

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Imaging Findings

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  • CT scans of the lower thorax and abdomen: Demonstrate pleural effusions, ascites, peritoneal and mesenteric thickening, and low-density soft-tissue masses involving the omentum and peritoneum

    • Malignant mesothelioma may have evidence of asbestos exposure on chest film as well pleural plaques on thoracic CT

    • In pseudomyxoma peritonei, US and CT scans show distinctive peritoneal scalloping of the liver margin and intra-abdominal calcified plaques

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  • • Chronic inflammatory peritonitis

    • Peritoneal mesothelioma

    • Cystic mesotheliomas

    • Well-differentiated papillary mesotheliomas

    • Pseudomyxoma peritonei

    • Benign appendiceal mucocele

    • Mesenteric cyst

    • Mesenteric lipodystrophy

    • Carcinomatosis

    • Abdominal lymphoma

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Rule Out

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  • • Carcinomatosis

    • Chronic inflammatory peritonitis

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  • • Thorough history (including asbestos exposure) and physical exam

    • Abdominal pelvic CT scan to evaluate extent of lesion(s)

    • Chest film or thoracic CT scan to evaluate for metastatic disease

    • Diagnostic paracentesis: Lactic dehydrogenase (LDH) level, albumin, amylase, triglyceride level, WBC count, cytologic studies, Gram stain, and culture

    • Percutaneous biopsy of accessible peritoneal thickening vs diagnostic laparoscopy with biopsy

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When to Admit

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  • • Symptoms seldom develop until advanced stages of disease, at which time patients have abdominal pain, distention, and frequently small bowel obstruction requiring admission

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When to Refer

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  • • General surgeons instrumental in establishing the diagnosis, performing cytoreductive surgery, and administering intraperitoneal chemotherapy in conjunction with medical oncology

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  • • Palliative cytoreductive surgery: Gross tumor debulking and omentectomy (plus appendectomy and bilateral salpingo-oopherectomy in pseudomyxoma peritonei)

    • Intraperitoneal chemotherapy

    • Adjuvant intracavitary radiation

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Surgery

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Indications

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  • • Bowel obstruction

    • Malignant fistula formation

    • Palliation

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Medications

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  • • Cisplatin/doxorubicin-based adjuvant chemotherapy for malignant mesothelioma

    • Fluorouracil-based adjuvant chemotherapy for pseudomyxoma peritonei

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