Fonte Rodolfo, Gambettino Salvatore, Melazzini Mario, Scelsi Mario, Zanon Claudio, Candura Stefano M
Division of Occupational Medicine, Salvatore Maugeri Foundation, Work and Rehabilitation, IRCCS, Scientific Institute of Pavia, Via Ferrata 8, I-27100 Pavia, Italy.
Environ Health Perspect. 2004 Apr;112(5):616-9. doi: 10.1289/ehp.6542.
Occupational and environmental asbestos exposure continues to represent a public health problem, despite increasingly restrictive laws adopted by most industrialized countries. Peritoneal mesothelioma is a rare and aggressive asbestos-related malignancy. We present the case of a 65-year-old man who developed recurrent ascites after having been exposed to asbestos in the building industry for > 40 years. Liver function and histology were normal. Abdominal computed tomography initially excluded the presence of expansive processes, and no abnormal cells were found in the ascitic fluid. Laparoscopy showed diffuse neoplastic infiltration of the peritoneum. Histopathology of bioptic samples revealed epithelioid neoplastic proliferation with a tubulopapillary pattern, falsely suggesting metastatic adenocarcinomatosis. In consideration of the occupational history, and after further diagnostic procedures had failed to identify the hypothetical primitive tumor, immunostaining of the neoplastic tissue was performed. Results were negative for carcinoembrionary antigen and the epithelial glycoprotein Ber-EP4, whereas results were positive for the mesothelial markers cytokeratins, calretinin, epithelial membrane antigen, and HBME-1, thus leading to the correct diagnosis of peritoneal epithelial mesothelioma. The Italian Workers' Compensation Authority recognized the occupational origin of the disease. Cytoreductive surgery associated with continuous hyperthermic peritoneal perfusion (cisplatin at 42 degrees C, for 1 hr) was performed. The disease relapsed after 4 months and was later complicated by a bowel obstruction requiring palliative ileostomy. The patient died 23 months after diagnosis. This case illustrates the insidious diagnostic problems posed by peritoneal mesothelioma, a tumor which often simulates other malignancies (e.g., metastatic carcinomas) at routine histopathological examination. Occupational history and immunohistochemistry are helpful for the correct diagnosis, which, in turn, is important in relation to prognosis and treatment (adoption of new integrated procedures that seem to promise prolonged survival and increased quality of life), and in relation to medicolegal issues and occupation-related compensation claims following asbestos exposure.
尽管大多数工业化国家已出台日益严格的法律，但职业性和环境性石棉暴露仍是一个公共卫生问题。腹膜间皮瘤是一种罕见且侵袭性强的与石棉相关的恶性肿瘤。我们报告一例65岁男性病例，该患者在建筑行业接触石棉超过40年后出现反复腹水。肝功能和组织学检查均正常。腹部计算机断层扫描最初排除了占位性病变的存在，腹水未发现异常细胞。腹腔镜检查显示腹膜弥漫性肿瘤浸润。活检样本的组织病理学显示上皮样肿瘤增生，呈管状乳头模式，易误诊为转移性腺癌。考虑到职业史，在进一步诊断程序未能确定假想的原发肿瘤后，对肿瘤组织进行了免疫染色。癌胚抗原和上皮糖蛋白Ber-EP4结果为阴性，而间皮标记物细胞角蛋白、钙视网膜蛋白、上皮膜抗原和HBME-1结果为阳性，从而确诊为腹膜上皮性间皮瘤。意大利工人赔偿局认定该疾病的职业性起源。进行了细胞减灭术联合持续高温腹膜灌注（42℃顺铂，持续1小时）。疾病在4个月后复发，随后并发肠梗阻，需要进行姑息性回肠造口术。患者在诊断后23个月死亡。该病例说明了腹膜间皮瘤带来的隐匿性诊断问题，这种肿瘤在常规组织病理学检查中常模拟其他恶性肿瘤（如转移性癌）。职业史和免疫组织化学有助于正确诊断，而正确诊断对于预后和治疗（采用似乎有望延长生存期和提高生活质量的新综合程序）以及与石棉暴露后的法医学问题和职业相关赔偿要求都很重要。
