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Table of Contents
CLINICAL IMAGE
Year : 2022  |  Volume : 11  |  Issue : 2  |  Page : 137-138

Benign multicystic peritoneal mesothelioma complicating fertility preservation


1 Department of Obstetrics and Gynecology, Sapporo Medical University School of Medicine, Sapporo; Department of Obstetrics and Gynecology, Hokkaido Institutional Society Obihiro Hospital, Obihiro, Japan
2 Department of Obstetrics and Gynecology, Sapporo Medical University School of Medicine, Sapporo, Japan

Date of Submission13-Apr-2021
Date of Decision28-Sep-2021
Date of Acceptance23-Dec-2021
Date of Web Publication4-May-2022

Correspondence Address:
Dr. Tasuku Mariya
Sapporo Medical University School of Medicine, South 1 West 17, Chuo-ku, Sapporo 060-8556
Japan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/GMIT.GMIT_43_21

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How to cite this article:
Shikanai S, Mariya T, Iwasaki M, Saito T. Benign multicystic peritoneal mesothelioma complicating fertility preservation. Gynecol Minim Invasive Ther 2022;11:137-8

How to cite this URL:
Shikanai S, Mariya T, Iwasaki M, Saito T. Benign multicystic peritoneal mesothelioma complicating fertility preservation. Gynecol Minim Invasive Ther [serial online] 2022 [cited 2022 May 20];11:137-8. Available from: https://www.e-gmit.com/text.asp?2022/11/2/137/344791



A 32-year-old nulliparous woman was diagnosed with left breast cancer and was referred to our gynecology department soon after diagnosis for preserving fertility before neoadjuvant chemotherapy. Egg collection and cryopreservation were considered, but we identified multiple cysts in the rectouterine pouch by transvaginal ultrasonography. The cyst was not palpable by pelvic examination, and she had no complaint of any symptoms about the cysts. It was considered to be difficult to approach the ovaries transvaginally with avoidance of the cysts. There was no elevation of tumor markers (CEA, CA125, and CA19-9) in the blood test. MRI showed multiple cysts filling the rectouterine pouch, which did not lead to a definitive diagnosis, although malignancy was not strongly suspected [Figure 1]. We counseled her on fertility preservation techniques and told her that there were two options: egg retrieval and cryopreservation, and ovarian tissue freezing with pelvic cystectomy at the same time. We informed her that the cysts needed to be penetrated for transvaginal egg retrieval, but it was difficult to make a definitive diagnosis of whether the cysts were benign or malignant in advance. Furthermore, the breast cancer doctor did not like the hormonal stimulation for ovulation and the several weeks' delays of chemotherapy for egg retrieval. Finally, she chose pelvic cystectomy and ovarian tissue freezing. We decided to perform a laparoscopic approach for the multiple cysts and ovarian tissue freezing. Laparoscopic observation revealed dense cysts of various shapes attached to the posterior surface of the uterus [Figure 2]a. The right ovary was excised and frozen, and the pelvic cysts were completely resected with an ultrasonic coagulation device, and the posterior wall of the uterus was cauterized [Figure 2]b. There was sufficient ovarian tissue volume for freezing. The pathological diagnosis of the cyst being consistent with results of multiple histology was benign multicystic peritoneal mesothelioma [BMPM; [Figure 3]a] and endometrial cyst [Figure 3]b. She was discharged from the hospital 4 days after the surgery without any complications and smoothly started neoadjuvant chemotherapy the next week.
Figure 1: Magnetic resonance images of the pelvic cysts. T2-weighted magnetic resonance images of the sagittal (a) and axial planes. (b) Triangles show multiple cysts of the rectouterine pouch

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Figure 2: Laparoscopic findings of the pelvic cysts. (a) Pelvic cysts of various shapes originated from the posterior wall of the uterus. (b) After resection of the cysts and cauterization of the posterior wall of the uterus (triangle). The right ovary was also resected and frozen for preservation (arrow)

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Figure 3: Histopathological findings of the resected cysts and right Fallopian tube. (a) Cysts lined by flattened mesothelial cells without atypia. (b) Endometrial stroma-like lesion with hemosiderin-laden macrophages. (c) Right Fallopian tube immunohistochemically stained by a p53 antibody. Highly stained fimbria of the tube was diagnosed as a p53 signature

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Although BMPM is generally considered to be benign because no cellular or nuclear atypia is seen by histological examination,[1],[2] the local recurrence rate has been reported to be high.[3],[4] It was reported that the timing of recurrence of BMPM ranged from early to late (from 1 month to 36 years) after surgical treatment.[5],[6] BMPM is sometimes accompanied by endometriosis like our case, and some reports suggested that chronic pelvic inflammation with endometriosis is one of the causes of endometriosis.[7] There are some reports of egg retrieval and cryopreservation penetrating pelvic cysts, even in malignant mesothelioma cases.[8] Therefore, vaginal egg retrieval could have been considered in our case if the patient had requested it or had time to delay chemotherapy. The excised cysts included endometriosis, but after neoadjuvant chemotherapy for breast cancer, the patient had a premature menopausal situation. Therefore, we think that there is no current risk of progression of endometriosis, and the patient is being followed up without further treatment. There is no recurrence of pelvic cysts at 1 year postoperatively.

Our patient was young and had a strong desire to have a baby. For such patients, the timing of reproductive health interventions after breast cancer treatment should be carefully discussed. In our patient, genetic counseling for Hereditary Breast and Ovarian Cancer syndrome (HBOC) was performed because of the patient was a young breast cancer patient and a p53 signature was found in the right Fallopian tube by the SEE-FIM protocol [Figure 3]c. Although she had no familial history of HBOC-related cancer to her knowledge, she hoped for BRCA gene testing and her results were negative for germline mutation after genetic counseling. Therefore, she chose preservation of her normal right breast and the partial resection of her left breast after neoadjuvant chemotherapy.

Acknowledgment

We thank SES translation services (Sapporo, Japan) for editing a draft of this manuscript.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Chand MT, Edens J, Lin T, Anderson I, Berri R. Benign multicystic peritoneal mesothelioma: Literature review and update. Autops Case Rep 2020;10:e2020159.  Back to cited text no. 1
    
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Aziz H, Hao M, Merchant A, Alfson D, Foran C, Raashid Sheikh M. Benign multi-cystic peritoneal mesothelioma of the porta hepatis. Int J Surg Case Rep 2020;74:218-21.  Back to cited text no. 2
    
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González-Moreno S, Yan H, Alcorn KW, Sugarbaker PH. Malignant transformation of “benign” cystic mesothelioma of the peritoneum. J Surg Oncol 2002;79:243-51.  Back to cited text no. 3
    
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Gussago S, Spina P, Guerra A. Benign multicystic peritoneal mesothelioma (BMPM) as a rare cause of abdominal pain in a young male: Case report and review of the literature. J Surg Case Rep 2019;2019:rjz057.  Back to cited text no. 4
    
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Testa AC, Zannoni GF, Ferrari S, Lecca A, Marana E, Marana R. Benign cystic peritoneal mesothelioma incorrectly diagnosed as an ovarian borderline mucinous tumor of intestinal type at transvaginal preoperative ultrasound evaluation. Ultrasound Obstet Gynecol 2011;37:248-50.  Back to cited text no. 5
    
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Lee CE, Agrawal A. Remote recurrence of benign multicystic peritoneal mesothelioma. J Obstet Gynaecol Can 2017;39:1042-5.  Back to cited text no. 6
    
7.
Kurisu Y, Tsuji M, Shibayama Y, Yamada T, Ohmichi M. Multicystic mesothelioma caused by endometriosis: 2 case reports and review of the literature. Int J Gynecol Pathol 2011;30:163-6.  Back to cited text no. 7
    
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Filippi F, Kusamura S, Martinelli F, Somigliana E, Deraco M. Fertility preservation in women with peritoneal surface malignancies: A case series. Eur J Surg Oncol 2021;47:2948-51.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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