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Greetings! I hope you are well.

I am writing on behalf of an international publishing house, Science and Education Publishing, USA (http://www.sciepub.com).

Science and Education Publishing (SciEP) is a multidisciplinary open access publisher of Journals covering the fields of Science, Technology and Medicine. All SciEP publications are subject to high-quality peer review, editorial and production processes and are freely available online.

Welcome to the April, 2013 edition of SciEP newsletter, providing monthly summaries of articles on science & education related topics of interest to scientist and professionals. The mission of our journals is to provide an open access forum for publishing new findings on issues pertinent to scientific and academic field. We also invite you to submit original research papers, review articles, short reports, or case studies are considered for publication in our Multidisciplinary Journals.

American Journal of Public Health Research
DOI: 10.12691/ajphr-1-1-3

The Implementation of a Tele-Homecare System with Service Oriented Architecture and HL7 Message Transmission Standard
Ching-Sung Wang

American Journal of Medical and Biological Research
DOI: 10.12691/ajmbr-1-1-2

The Influence of Ethanol on Pyruvate Kinases Activity in Vivo, in Vitro, in Silico
Lelevich Sergey Vladimirovich, Khrustalev Vladislav Victorovich, Barkovsky Eugene Victorovich, Shedogubova Tatyana Aleksandrovna

American Journal of Medical Sciences and Medicine
DOI: 10.12691/ajmsm-1-1-1

Clinical and Histological Features in Wegener Granulomatosis
Li Cavoli Gioacchino, Passantino Rita, Bono Luisa, Tortorici Calogera, Ferrantelli Angelo, Giammarresi Carlo, Rotolo Ugo

American Journal of Infectious Diseases and Microbiology
DOI: 10.12691/ajidm-1-1-2

The Curse of Lymphatic Filariasis: Would the Continual Use of Diethylcarbamazine Eliminate this Scourge in Papua New Guinea?
Anne Lanham, Lillian Mwanri

We have released issues of some journals on February 2013.
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American Journal of Medical Sciences and Medicine
American Journal of Medical and Biological Research
American Journal of Pharmacological Sciences
American Journal of Clinical Medicine Research
American Journal of Nursing Research
American Journal of Cancer Prevention
American Journal of Medicine Studies
American Journal of Infectious Diseases and Microbiology
American Journal of Cardiovascular Disease Research
American Journal of Biomedical Research
American Journal of Mechanical Engineering
American Journal of Microbiological Research
Journal of Preventive Medicine
American Journal of Food and Nutrition
American Journal of Hypertension Research
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Journal of Cancer Research and Treatment
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Label_Title

Dear Label_Name,

Greetings! I hope you are well.

I am writing on behalf of an international publishing house, Science and Education Publishing, USA (http://www.sciepub.com).

Science and Education Publishing (SciEP) is a multidisciplinary open access publisher of Journals covering the fields of Science, Technology and Medicine. All SciEP publications are subject to high-quality peer review, editorial and production processes and are freely available online.

Welcome to the April, 2013 edition of SciEP newsletter, providing monthly summaries of articles on science & education related topics of interest to scientist and professionals. The mission of our journals is to provide an open access forum for publishing new findings on issues pertinent to scientific and academic field. We also invite you to submit original research papers, review articles, short reports, or case studies are considered for publication in our Multidisciplinary Journals.

American Journal of Public Health Research
DOI: 10.12691/ajphr-1-1-3

The Implementation of a Tele-Homecare System with Service Oriented Architecture and HL7 Message Transmission Standard
Ching-Sung Wang

American Journal of Medical and Biological Research
DOI: 10.12691/ajmbr-1-1-2

The Influence of Ethanol on Pyruvate Kinases Activity in Vivo, in Vitro, in Silico
Lelevich Sergey Vladimirovich, Khrustalev Vladislav Victorovich, Barkovsky Eugene Victorovich, Shedogubova Tatyana Aleksandrovna

American Journal of Medical Sciences and Medicine
DOI: 10.12691/ajmsm-1-1-1

Clinical and Histological Features in Wegener Granulomatosis
Li Cavoli Gioacchino, Passantino Rita, Bono Luisa, Tortorici Calogera, Ferrantelli Angelo, Giammarresi Carlo, Rotolo Ugo

American Journal of Infectious Diseases and Microbiology
DOI: 10.12691/ajidm-1-1-2

The Curse of Lymphatic Filariasis: Would the Continual Use of Diethylcarbamazine Eliminate this Scourge in Papua New Guinea?
Anne Lanham, Lillian Mwanri

We have released issues of some journals on February 2013.
American Journal of Public Health Research
American Journal of Medical Sciences and Medicine
American Journal of Medical and Biological Research
American Journal of Pharmacological Sciences
American Journal of Clinical Medicine Research
American Journal of Nursing Research
American Journal of Cancer Prevention
American Journal of Medicine Studies
American Journal of Infectious Diseases and Microbiology
American Journal of Cardiovascular Disease Research
American Journal of Biomedical Research
American Journal of Mechanical Engineering
American Journal of Microbiological Research
Journal of Preventive Medicine
American Journal of Food and Nutrition
American Journal of Hypertension Research
American Journal of Sports Science and Medicine
Journal of Cancer Research and Treatment
American Journal of Zoological Research
Journal of Biomedical Engineering and Technology
American Journal of Microbiological Research
Biomedical Science and Engineering

We are pleased to announce that submissions are now being accepted for peer review for all the journals across all our subject areas in SciEP.

Please submit your manuscript via our online submission system:
http://www.sciepub.com/author/signin

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I am looking forward to hearing from you.

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David Rain
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Science and Education Publishing (http://www.sciepub.com)

Deceived by Ultrasound: An Unexpected Discovery of Aggressive Peritoneal Malignancy Disguised as a Benign Gynecologic Complaint

Lev Tohar*, Gerk Alexis, Lentz Kristen, Bachman Ira

Obstetrics and Gynecology, Mount Sinai South Nassau, Oceanside, NY

Abstract: Commonly diagnosed at an advanced stage, peritoneal mesothelioma is a rare and highly aggressive malignancy. This case demonstrates an atypical presentation of sarcomatoid mesothelioma, identified by gynecologists due to concern for hemorrhagic cyst.

Keywords: sarcomatoid, mesothelioma, hemorrhagic cyst, oncology

Received May 02, 2025; Revised June 03, 2025; Accepted June 10, 2025

Citation: Lev Tohar, Gerk Alexis, Lentz Kristen, Bachman Ira, Deceived by Ultrasound: An Unexpected Discovery of Aggressive Peritoneal Malignancy Disguised as a Benign Gynecologic Complaint. American Journal of Medical Case Reports, 13 (3). 19-21. January 2025. doi:10.12691/ajmcr-13-3-3

1. Introduction

Although commonly pleural in origin, mesothelioma may develop in the mesothelial cells lining other serous cavities with malignant peritoneal mesothelioma being one of few primary peritoneal neoplasms. Both pleural and peritoneal mesothelioma share asbestos exposure as a primary risk factor, however, their gene expression profile and molecular pathogenesis differ significantly. [1]. Men are noted to have higher incidence of mesothelioma of all types with a 3-4:1 male predominance in pleural varieties, though a larger proportion of women will develop peritoneal mesothelioma [2,3].

Presenting with nonspecific symptoms such as abdominal discomfort/ pain, distention, increased abdominal girth, nausea, early satiety, and weight loss, many patients are at an advanced stage of disease when evaluated with classification further delayed by the challenges and complexity of diagnostic methods. Laboratory testing can demonstrate elevations in cancer antigen 125 (CA125), carcinoembryonic antigen (CEA), and soluble mesothelin related protein (SMRP) with low specificity. Imaging with CT, or MRI for those that cannot receive IV contrast, may reveal ascites, sheetlike thickening of the peritoneum with peritoneal nodules, or distinct masses with peritoneal studding suggesting peritoneal mesothelioma, but tissue sampling is required for diagnosis. Sampling may be achieved by core needle or laparoscopic biopsy, however, if disease suspicion is high, laparoscopic tracts should be excised during the procedure due to the propensity to seed the port sites [4,5].

Cytology of ascitic fluid is often non diagnostic or inconclusive as it cannot establish the degree of invasion into the peritoneum or viscera to define malignancy. Biopsies obtained should undergo immunohistochemical staining for calretinin, cytokeratins 5 and 6, mesothelin, and Wilms tumor 1 antigen. Of the four subtypes of peritoneal mesothelioma (epithelioid, sarcomatoid, mixed, and well-differentiated papillary), sarcomatoid is the most rare and associated with the highest rates of mortality [6,7,8].

2. Case Report

Our patient is a 29 year old G2P1011 female with no significant past medical history who initially presented for right lower quadrant pain. Initial evaluation revealed a benign abdominal exam and transvaginal ultrasound remarkable for a right-sided hemorrhagic cyst with mild-to-moderate pelvic free fluid. Laboratory findings included anemia (hemoglobin: 5.9 g/dL) and clinical picture was concerning for a ruptured hemorrhagic cyst. The patient received 2 units of packed red blood cells for anemia and was admitted for observation and serial abdominal exams in the setting of suspected hemorrhagic cyst. On hospital day two, the patient’s hemoglobin rose appropriately to 10.2 g/dL. The patient remained hemodynamically and clinically stable with improved pain and was subsequently discharged home.

Five days later, the patient returned with recurrent right lower quadrant pain and bloating. At that time, her abdominal exam was notable for moderate distention and positive fluid wave. Bimanual exam was unremarkable with bilateral adnexa nontender and non enlarged. Imaging revealed an enlarged right ovary with heterogeneous 3.3cm cyst with layering hemorrhagic content and interval increase in moderate to marked abdominopelvic complex ascites as well as a right pleural effusion. Given the patient’s secondary presentation for similar complaints, the decision was made to take the patient to the operating room for diagnostic laparoscopy. During the case, greater than 1500cc serous fluid was evacuated. Diffuse peritoneal and bowel nodularity and studding, peritonitis, and pelvic adhesions were noted; however, there was no evidence of a hemorrhagic cyst visualized. Subsequently, cytology was found to be negative for malignant cells. Patient was discharged home on postoperative day one in stable condition.

The patient then re-presented on postoperative day eight with similar complaints. CTAP performed showing soft tissue nodularity along the omentum, and large volume complex ascites suggestive of hemorrhagic fluid. IR guided paracentesis was performed with evacuation of 2.8L of clear yellow fluid. Peritoneal biopsies were collected and sent to an expert pathologist. Final pathology revealed sarcomatoid mesothelioma and the patient was referred to a tertiary care center for further management and treatment.

3. Discussion

When analyzing the case retrospectively, the first point the authors discussed was the initial medical management of what was suspected to be a hemorrhagic cyst. Without significant demographic or environmental risk factors or comorbidities and with nonspecific clinical complaints, this presentation of a healthy young adult P1 with right lower quadrant pain and anemia thought to be explained by ultrasonographic findings of the cyst warranted a discussion with the patient about medical versus surgical management for which the patient, after weighing risk and benefits, opted for medical management and outpatient follow-up. Offering the patient medical management at that time with serial exams and appropriate rise in hemoglobin and hematocrit remains a reasonable option given the case.

On her second presentation, however, her pain presented with associated bloating and positive fluid wave on exam concerning for other etiologies despite imaging again reading as this hemorrhagic cyst, ultimately leading to the decision for diagnostic laparoscopy. In retrospect, the authors discussed once peritoneal and bowel nodularity and studding with large amount of serous fluid and no identifiable hemorrhagic cyst were seen, should other subspecialties have been consulted intraoperatively for more further evaluation including peritoneal biopsies and potential staging?

During this second presentation, only cytology from the evacuated fluid rather than biopsies was collected and no additional imaging was done including CTAP following the procedure’s findings. These were delayed until her third presentation on postoperative day eight and significantly delayed her diagnosis and her referral to specialty treatment. That said, the availability of subspecialty care including gynecologic oncology for intraoperative consultation may be limited in many institutions and potentially should influence timing of such cases when more personnel are available given the concerning findings of new onset bloating and ascites.

In addition to diagnostic utility, early laparoscopy combined with appropriate imaging can assist in evaluation of which patients would benefit from cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. Without having high clinical suspicion for malignancy when the patient presented, such surgical planning was not done at the time, but should be considered in future cases with similar findings if appropriate subspecialists are available [9,10,11,12].

4. Conclusion

This case initially presented as a typical, uncomplicated ruptured hemorrhagic cyst. The patient was initially managed medically, however when the patient presented with recurring symptoms the decision was made for surgical interventions.

This case underscores the importance of maintaining a broad differential diagnosis, particularly when evaluating recurrent presentations with unexplained ascites and peritoneal abnormalities. This also highlights the importance of having a low threshold for obtaining a biopsy in cases with uncertain diagnoses.

Mesothelioma is most commonly pleural in origin, however the peritoneal type has female predominance. Cytology of ascitic fluid is often non-diagnostic, and biopsies should be performed for evaluation of invasion and immunohistological staining. Sarcomatoid mesothelioma is the rarest form and associated with the highest rate of mortality, with median survival ranging from 3.5 to 8 months. Our patient was referred to a tertiary care center for further specialized management.

References

[1]   | Seshadri, Anupamaa, and Erika Rangel. "Peritoneal Cavity." Current Diagnosis & Treatment: Surgery, 15e Ed. Gerard M. Doherty. McGraw Hill LLC, 2020, https://accessmedicine-mhmedical-com.neomed.idm.oclc.org/ content.aspx? bookid=2859 & sectionid=242157732.
[2]   | Fels Elliott DR, Jones KD. Diagnosis of Mesothelioma. Surg Pathol Clin. 2020 Mar; 13(1): 73-89.
[3]   | Steadman JA, Grotz TE. Principles of Surgical Management of Peritoneal Mesothelioma. J Natl Compr Canc Netw. 2023 Sep; 21(9): 981-986.
[4]   | Verma V, Sleightholm RL, Rusthoven CG, Koshy M, Sher DJ, Grover S, Simone CB 2nd. Malignant Peritoneal Mesothelioma: National Practice Patterns, Outcomes, and Predictors of Survival. Ann Surg Oncol. 2018 Jul; 25(7): 2018-2026.
[5]   | Calthorpe L, Romero-Hernandez F, Miller P, Conroy PC, Hirose K, Kim A, Kirkwood K, Nakakura E, Corvera C, Maker AV, Alseidi A, Adam MA. Contemporary Trends in Malignant Peritoneal Mesothelioma: Incidence and Survival in the United States. Cancers (Basel). 2022 Dec 30; 15(1): 229.
[6]   | Kindler HL. Peritoneal mesothelioma: the site of origin matters. Am Soc Clin Oncol Educ Book. 2013:182-8.
[7]   | Notue YA, Mbessoh UI, Nganwa G, Pambe JN, Mefire AC, Moifo B, Sando Z. Sarcomatoid malignant peritoneal mesothelioma presenting as a localized mesenteric tumor with no previous asbestos exposure. J Surg Case Rep. 2020 Oct 28; 2020(10): rjaa419.
[8]   | Chun CP, Song LX, Zhang HP, Guo DD, Xu GX, Li Y, Xin X, Cao J, Li F. Malignant peritoneal mesothelioma. Am J Med Sci. 2023 Jan; 365(1):99-103.
[9]   | Zhang CH, Yu JW, Luo M. Multicystic peritoneal mesothelioma: A short review. Curr Probl Cancer. 2017 Sep-Oct; 41(5): 340-348.
[10]   | Noiret B, Renaud F, Piessen G, Eveno C. Multicystic peritoneal mesothelioma: a systematic review of the literature. Pleura Peritoneum. 2019 Sep 25; 4(3): 20190024.
[11]   | Bravo R, Jafari MD, Pigazzi A. The Utility of Diagnostic Laparoscopy in Patients Being Evaluated for Cytoreductive Surgery and Hyperthermic Peritoneal Chemotherapy. Am J Clin Oncol. 2018 Dec; 41(12): 1231-1234.
[12]   | Valle M, Federici O, Garofalo A. Patient selection for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy, and role of laparoscopy in diagnosis, staging, and treatment. Surg Oncol Clin N Am. 2012 Oct; 21(4): 515-31.