Cytology of benign multicystic peritoneal mesothelioma in peritoneal washings

Objective:  To describe the cytological aspect of peritoneal washings in benign multicystic peritoneal mesothelioma (BMPM).
Methods:  Three peritoneal washing specimens stained by standard cytological and histological procedures and analysed by light microscopy.
Results:  The specimens showed an abundance of monomorphous mesothelial cells devoid of atypia or mitoses. The mesothelial cells were calretinin positive. They also showed numerous squamous metaplastic cells arranged in flat sheets or isolated cells. The background contained some inflammatory cells.
Conclusion:  The combination of cytology of the peritoneal washing, histology (cell block and surgical specimen) and clinical history allow differentiation of BMPM from other cystic lesions (cystic lymphangioma and malignant mesothelioma).     

Cytologic findings in multicystic peritoneal mesothelioma

The cytologic findings in a case of multicystic peritoneal mesothelioma are presented. A 70-year-old man had a slowly enlarging and intermittently painful abdominal mass that was multicystic and avascular on radiologic evaluation. Percutaneous drainage of the mass was performed over a four-year period for symptomatic relief. Large sheets of benign mesothelial cells were consistently present in the cytologic preparations of each of the drainage specimens. The mass has remained localized to the abdomen, and the patient is alive and well seven years after the onset of symptoms. The radiologic features and the clinical course of the patient were most suggestive of a rare benign multicystic peritoneal mesothelioma; the cytologic findings supported this diagnosis. A review of the pertinent literature is presented.     

Study on the ultrastructure of the peritoneal stomata in humans.

In 16 human specimens the topography and organization of stomata and mesothelial cells of the diaphragmatic, pelvic wall and anterior abdominal wall peritoneum were studied by transmission electron microscopy, scanning electron microscopy and the image processing technique. The mesothelial cells were organized into two discrete populations, cuboidal cells and flattened cells. The stomata were found only among cuboidal cells, either on the muscular portion or on the tendinous portion of the diaphragm. The size and shape of stomata, which were arranged in a cluster or a strip, were often irregular. The average area of a stoma on the muscular portion was 10.43 +/- 1.61 microns2, on the tendinous portion 7.93 +/- 1.67 microns2. Stomata opened to submesothelial connective tissue, under which numerous lymphatics were observed. Stomata were not discovered in the pelvic and anterior abdominal wall peritoneum. In animal experiments intraperitoneally injected trypan blue particles were rapidly removed from the peritoneal cavity through stomata of the diaphragmatic peritoneum in rabbits. It is suggested that stomata may be the main pathway for draining matter from the peritoneal cavity and that the diaphragmatic peritoneum shows the strongest absorption in all parts of the peritoneum.     

Intraoperative Detection of Subtle Endometriosis: A Novel Paradigm for Detection and Treatment of Pelvic Pain Associated with the Loss of Peritoneal Integrity

Endometriosis is a common disease affecting 40 to 70% of reproductive-aged women with chronic pelvic pain (CPP) and/or infertility. The purpose of this study was to demonstrate the use of a blue dye (methylene blue) to stain peritoneal surfaces during laparoscopy (L/S) to detect the loss of peritoneal integrity in patients with pelvic pain and suspected endometriosis. Forty women with CPP and 5 women without pain were evaluated in this pilot study. During L/S, concentrated dye was sprayed onto peritoneal surfaces, then aspirated and rinsed with Lactated Ringers solution. Areas of localized dye uptake were evaluated for the presence of visible endometriotic lesions. Areas of intense peritoneal staining were resected and some fixed in 2.5% buffered gluteraldehyde and examined by scanning (SEM) electron microscopy. Blue dye uptake was more common in women with endometriosis and chronic pelvic pain than controls (85% vs. 40%). Resection of the blue stained areas revealed endometriosis by SEM and loss of peritoneal cell-cell contact compared to normal, non-staining peritoneum. Affected peritoneum was associated with visible endometriotic implants in most but not all patients. Subjective pain relief was reported in 80% of subjects. Based on scanning electron microscopy, we conclude that endometrial cells extend well beyond visible implants of endometriosis and appear to disrupt the underlying mesothelium. Subtle lesions of endometriosis could therefore cause pelvic pain by disruption of peritoneal integrity, allowing menstrual or ovulatory blood and associated pain factors access to underlying sensory nerves. Complete resection of affected peritoneum may provide a better long-term treatment for endometriosis and CPP. This simple technique appears to improve detection of subtle or near invisible endometriosis in women with CPP and minimal visual findings at L/S and may serve to elevate diagnostic accuracy for endometriosis at laparoscopy.     

Expression of matrix metalloproteinases-2 and -9 by cells isolated from the peritoneal fluid of women with ovarian carcinoma

OBJECTIVE: To investigate the level of expression of matrix metalloproteinases (MMP)-2 and -9 by cells isolated from the peritoneal fluid of women with ovarian carcinoma. STUDY DESIGN: Tumor tissue specimens and cells isolated from peritoneal fluid from 20 patients with epithelial ovarian carcinoma were examined for MMP-2 and -9 expression using immunostaining. Six benign peritoneal effusions containing mesothelial cells were also included in the study. RESULTS: Expression of both MMP-2 and -9 was noted in cancer cells in peritoneal fluid of all cases studied. Peritoneal fluid cancer cells showed increased expression of both MMP-2 and -9 relative to mesothelial cell expression of these MMPs. Positive immunoreactivity of these MMPs in primary tumor tissues was confirmed by immunohistochemistry. CONCLUSION: Our findings suggest that both MMP-2 and -9 are frequently overexpressed in ovarian cancer cells disseminated in the peritoneal cavity and that determination of cellular MMP-2 and -9 expression could be useful in distinguishing cancer cells from mesothelial cells in peritoneal fluid cytologic specimens from women with ovarian epithelial carcinoma.     

The Peritoneum Is Both a Source and Target of TGF-β in Women with Endometriosis

Transforming growth factor-β (TGF-β) is believed to play a major role in the aetiology of peritoneal endometriosis. We aimed to determine if the peritoneum is a source of TGF-β and if peritoneal TGF-β expression, reception or target genes are altered in women with endometriosis. Peritoneal fluid, peritoneal bushings and peritoneal biopsies were collected from women with and without endometriosis. TGF-β1, 2 and 3 protein concentrations were measured in the peritoneal fluid. TGF-β1 was measured in mesothelial cell conditioned media. Control peritoneum and peritoneum prone to endometriosis (within Pouch of Douglas) from women without disease (n = 16) and peritoneum distal and adjacent to endometriosis lesions in women with endometriosis (n = 15) and were analysed for TGF-β expression, reception and signalling by immunohistochemistry, qRT-PCR and a TGF-β signalling PCR array. TGF-β1 was increased in the peritoneal fluid of women with endometriosis compared to those without disease (P<0.05) and peritoneal mesothelial cells secrete TGF-β1 in-vitro. In women with endometriosis, peritoneum from sites adjacent to endometriosis lesions expressed higher levels of TGFB1 mRNA when compared to distal sites (P<0.05). The TGF-β-stimulated Smad 2/3 signalling pathway was active in the peritoneum and there were significant increases (P<0.05) in expression of genes associated with tumorigenesis (MAPK8, CDC6), epithelial-mesenchymal transition (NOTCH1), angiogenesis (ID1, ID3) and neurogenesis (CREB1) in the peritoneum of women with endometriosis. In conclusion, the peritoneum, and in particular, the peritoneal mesothelium, is a source of TGF-β1 and this is enhanced around endometriosis lesions. The expression of TGF-β-regulated genes is altered in the peritoneum of women with endometriosis and this may promote an environment favorable to lesion formation.     

Spontaneous peritoneal malignant mesothelioma in a geriatric japanese macaque (Macaca fuscata).

A 28.5-year-old female Japanese macaque (Macaca fuscata) was euthanatized because of abdominal distension due to severe ascites. Nodular lesions of varying sizes up to 5 mm in diameter were distributed diffusely on the surface of the omentum, mesentery and parietal peritoneum. No neoplastic masses were detected in any visceral organ. The nodules were composed of proliferation of mono- or multi-layered epithelial-like cells occasionally showing papillary growth and sheets of small round or polygonal cells. Signet ring-like cells and tubular structures were occasionally present. Neoplastic cells were strongly positive to cytokeratin, and occasionally to vimentin. Based on gross and histopathological findings, this tumor was diagnosed as an epithelial type of peritoneal malignant mesothelioma, the first reported case in the non-human primates.     

Modeling the Early Steps of Ovarian Cancer Dissemination in an Organotypic Culture of the Human Peritoneal Cavity

The pattern of ovarian cancer metastasis is markedly different from that of most other epithelial tumors, because it rarely spreads hematogenously. Instead, ovarian cancer cells exfoliated from the primary tumor are carried by peritoneal fluid to metastatic sites within the peritoneal cavity. These sites, most notably the abdominal peritoneum and omentum, are organs covered by a mesothelium-lined surface. To investigate the processes of ovarian cancer dissemination, we assembled a complex three-dimensional culture system that reconstructs the lining of the peritoneal cavity in vitro. Primary human fibroblasts and mesothelial cells were isolated from human omentum. The fibroblasts were then mixed with extracellular matrix and covered with a layer of the primary human mesothelial cells to mimic the peritoneal and omental surfaces encountered by metastasizing ovarian cancer cells. The resulting organotypic model is, as shown, used to examine the early steps of ovarian cancer dissemination, including cancer cell adhesion, invasion, and proliferation. This model has been used in a number of studies to investigate the role of the microenvironment (cellular and acellular) in early ovarian cancer dissemination. It has also been successfully adapted to high throughput screening and used to identify and test inhibitors of ovarian cancer metastasis.     

Rat adipose tissue-derived stem cells attenuate peritoneal injuries in rat zymosan-induced peritonitis accompanied by complement activation

Background aimsIn patients receiving peritoneal dialysis, fungal or yeast peritonitis has a poor prognosis. In rat peritoneum with mechanical scraping, severe peritonitis can be induced by zymosan, a component of yeast (Zy/scraping peritonitis). Administration of rat adipose tissue-derived stromal cells (ASCs) potentially can improve several tissue injuries. The present study investigated whether rat ASCs could improve peritoneal inflammation in Zy/scraping peritonitis.MethodsRat ASCs were injected intraperitoneally on a daily basis in rats with Zy/scraping peritonitis.ResultsPeritoneal inflammation accompanied by accumulation of inflammatory cells and complement deposition was suppressed by day 5 after injection of rat ASCs. The peritoneal mesothelial layer in Zy/scraping peritonitis with rat ASC treatment was restored compared with the peritoneal mesothelial layer without rat ASC treatment. Injected rat ASCs co-existed with mesothelial cells in the sub-peritoneal layer. In vitro assays showed increased cellular proliferation of rat mesothelial cells combined with rat ASCs by co-culture assays, confirming that fluid factors from rat ASCs might play some role in facilitating the recovery of rat mesothelial cells. Hepatocyte growth factor was released from rat ASCs, and administration of recombinant hepatocyte growth factor increased rat mesothelial cell proliferation.ConclusionsBecause the peritoneal mesothelium shows strong expression of membrane complement regulators such as Crry, CD55 and CD59, restoration of the mesothelial cell layer by rat ASCs might prevent deposition of complement activation products and ameliorate peritoneal injuries. This study suggests the therapeutic possibilities of intraperitoneal rat ASC injection to suppress peritoneal inflammation by restoring the mesothelial layer and decreasing complement activation in fungal or yeast peritonitis.     

Peritoneal fine structure of inguinal hernia: a transmission electron microscope study.

Fine structure of normal human parietal peritoneum served as control data for recording changes in the fine structure of the peritoneum of hernial sacs. In these sacs, mesothelial cells retracted, rounded up and some of them eventually separated altogether to give rise to wide open intercellular spaces thus creating unhindered passageways (stomata) between the subserosal connective tissue and the cavity of the sacs. There was a considerable collagen build-up in the subserosal fibrous tissue of hernial sacs. Occurrence of this fibrosis is at variance with an accepted surgical concept which suggests a defect in collagen synthesis as the cause of herniation. In some sacs mesothelial nodules and/or peritoneal adhesions were present. Certain cytological changes in the mesothelial cells of hernial sacs showed features in common with cells of malignant tumours in general, and features mimicking malignant mesotheliomas in particular. This is in spite of the fact that thorough gross and light microscopic examination of operative specimens and cytological evaluation of peritoneal effusion failed to reveal any evidence of malignancy. Pathologists should be aware of the consummate ability of mesothelial cells to mimic carcinomas in order to avoid possible diagnostic errors. In this report, an electron micrograph of peritoneal adhesion is being published for the first time in the literature. A syncytium-like firm bond between adjoining mesothelial cells constituted the adhesion which is obviously an irreversible process.     

Changes in the peritoneum of the small intestine and diaphragm in experimental portal hypertension

Diaphragm and small intestine peritoneum morphology was studied in experimental portal hypertension in rats with the help of luminescent, transmission and scanning electron microscopy techniques. Structural organizations of these peritoneum portions and performance function were different: fluid transudation realized through the small intestine peritoneum and resorption occurred via diaphragm peritoneum. Morphological signs allowed to judge about the increasing of fluid transudation in abdominal cavity and diaphragmatic resorption in early period of portal hypertension. Morphological alterations appeared in peritoneum resorption sites (pumping diaphragmatic hatchs) according to progress of portal hypertension that indicated decompensation process of peritoneal fluid absorption and led to ascites.     

The ultrastructure of the peritoneal membrane in chronically dialysed rats with spontaneous peritonitis: preliminary observations

In this paper we describe ultrastructure of the peritoneal membrane from single peritoneal biopsies collected from chronically dialysed rats with spontaneous peritonitis. The results were compared with those obtained in chronically dialysed animals without peritonitis. In rats with peritonitis, peritoneum was much thicker than in peritonitis-free animals. The increased thickness of the peritoneum during peritonitis was due to infiltration of the submesothelial tissue with oedematous fluid and to the presence of huge amount of cells in the stroma. The connective tissue cells were accumulated just underneath the peritoneal surface. In deeper parts of the interstitium, infiltrating acute inflammatory cells were present (lymphocytes, polymorphonuclear cells: neutrophils and eosinophils). Inversely, the increased thickness of the peritoneum in peritonitis-free animals was mainly due to enhanced amounts of collagen. Additionally, in rats with peritonitis, the surface was often denuded of mesothelial cells. The damaged mesothelial cells that detached from the peritoneal surface were also found. In conclusion, the morphological changes observed in rats with peritonitis are similar to those reported in humans, thus the model of peritonitis in dialysed rats can be used for the study of peritoneal remodeling during peritoneal dialysis complicated by peritonitis.     

Peritoneal washings in ovarian tumors. Potential sources of error in cytologic diagnosis

Peritoneal washings were performed on 48 patients with suspected or known ovarian carcinoma. The procedure was part of the initial surgical staging in 27 patients with presumed stage I and II ovarian cancer and was performed during second-look operations in 21 other cases with proven ovarian malignancy. This paper presents the microscopic features of the washings, with particular emphasis on the cytologic differentiation between benign and malignant findings outside of the ovary. Thirty-four cases showed benign or reactive mesothelial cells and no evidence of peritoneal disease. The washings of six patient showed malignant cells, which were confirmed histologically. Notable atypia that mimicked ovarian carcinoma was found in eight patients who had benign or borderline lesions. These findings included papillary and glandlike epithelial structures, with varying degrees of cellular atypia and psammoma bodies. The histologic counterparts of these atypicalities were Müllerian inclusions, mesothelial proliferations and borderline serous tumors. The differential diagnosis between these entities is essential because false-positive cytologic diagnoses may alter postoperative treatment in some patients.     

Synthesis and biological evaluation of sulfonyl acrylonitriles as novel inhibitors to peritoneal carcinomatosis

The vast majority of cancer patients die from metastasis, the process by which cancer cells spread to secondary tissues through body fluids. Peritoneal carcinomatosis is a type of metastasis in which cancer cells gain access to the intra-abdominal cavity and then implant in the peritoneum, the thin tissue that lines the abdominal wall and internal organs. Unfortunately, peritoneal carcinomatosis can occur following surgical resection of intra-abdominal malignancies. We previously reported proapoptotic activity of (2E)-3-[[4-(1,1-dimethylethyl)phenyl]sulfonyl]-2-propenenitrile (BAY 11-7085, 1) on colon and pancreatic cancer cells during adhesion and demonstrated that this compound could significantly inhibit peritoneal carcinomatosis in mice.(1,2) In order to determine the chemical basis of the anti-metastatic properties of BAY 11-7085, a series of analogs were synthesized and evaluated for their ability to induce apoptosis in pancreatic and ovarian cancer cells during adhesion to mesothelial cells, which line the surface of the peritoneum. The co-culture assay results were validated using a murine peritoneal carcinomatosis model. These analogs may greatly benefit patients undergoing surgical resections of colorectal, pancreatic, and ovarian cancers depending on their tolerability.     

Inflammation with restricted lysosomal proteolysis during early ascites carcinoma invasion of mouse parietal peritoneum. A medium and high-voltage electron microscopic and cytochemical study

A carcinoma invasion system (Krebs-2 and Ehrlich tetraploid ascites tumors invading mouse peritoneum) was studied by high-voltage electron microscope (HVEM) stereoscopy, conventional (medium voltage) electron microscopy (MVEM), and cytochemistry. Tumor cells entered areas of peritoneum (mainly parietal) only where mesothelial cells were damaged and where there was inflammation of the underlying stroma. The initial invasion was different from that of most other invading carcinomas in that there was minimal breakdown of basal lamina and collagen. Neither tumor cells, inflammatory leukocytes nor peritoneal fibroblasts showed significant secondary lysosome production or release of intracellular or extracellular acid phosphatase. Morphological and cytochemical criteria suggest that in some invading carcinomas, as with non-tumor migrating cells such as leukocytes, widespread proteolysis due to diffusion of proteases is not a prerequisite for invasion of stromal connective tissue.     

Comparison of NCL-hTERT antibody reactivity and telomere repeat amplification protocol in situ in effusions

OBJECTIVE: To compare the performances of 2 methods, telomerase repeat amplification protocol (TRAP) in situ and antibodies to the hTERT protein, in assessing telomerase activity. STUDY DESIGN: TRAP in situ and immunohistochemistry with a commercial antibody (NCL-hTERT) was performed on 54 body cavity effusions. The results were compared and correlated to diagnosis. RESULTS: Thirty-four effusions from patients with verified malignant disease contained cytologically malignant cells. Both methods were positive in 33 of the cases, whereas only hTERT was positive in 1 case. Twenty effusions, all containing mesothelial cells, came from patients with benign conditions. In 2 fluids atypical, hyperplastic mesothelial cells were both TRAP in situ and hTERT positive. All remaining 18 fluids were TRAP in situ negative, whereas 12 of 18 were hTERT positive. Thus the results of TRAP in situ and hTERT immunohistochemistry disagreed in 1 of 34 (3%) malignant and 12 of 20 (60%) benign cases. CONCLUSION: The sensitivities for malignancy were similar for TRAP in situ and hTERT immunohistochemistry. The specificity of the applied hTERT antibody was significantly lower, due to hTERT reactivity in mesothelial cells.     

Interactions of human ovarian tumor cells with human mesothelial cells grown on extracellular matrix : An in vitro model system for studying tumor cell adhesion and invasion

Human ovarian tumors metastasize by direct extension into the peritoneal cavity leading to tumor cell implantation onto peritoneal surfaces. Successful formation of peritoneal implants is dependent on the ability of ascitic tumor cells to infiltrate the mesothelium, and become firmly adherent to the underlying extracellular matrix (ECM). In order to investigate this process in more detail, an in vitro model system was developed employing human mesothelial cells grown on ECM-coated culture dishes. The ability of human ovarian carcinoma cells derived from ascitic fluid to attach to the mesothelial cell monolayer grown on ECM, ECM alone or plastic was quantitated with the use of 51Cr radio-labelled tumor cells. Tumor cells exhibited a more rapid and firmer attachment to ECM than to the mesothelial cells or to plastic. Using agitation to stimulate peritoneal fluid dynamics and shear forces in vivo, tumor cell arrest was found to be limited to the ECM, but it occurred at a slower rate than it did without agitation. Tumor cell attachment was also restricted to areas of exposed ECM in wounded mesothelium as assessed by phase-contrast microscopy. Morphologic alterations of the mesothelium induced by tumor cells were observed with the use of scanning electron microscopy (SEM) and immunohistochemical staining which included disruption of intercellular junctions leading to retraction of mesothelial cells, exposure of underlying ECM, subsequent attachment and proliferation on ECM. This model system would appear to be useful for elucidating mechanisms of ovarian tumor cell adhesion and proliferation, and for assessing various therapeutic modalities for their ability to block tumor cell implantation, invasion and growth on peritoneal surfaces.     

High Adhesion of Tumor Cells to Mesothelial Monolayers Derived from Peritoneal Wash of Disseminated Gastrointestinal Cancers

The role of the mesothelial layer in the peritoneal spreading of cancer cells is only partially clarified. Here we attempted to better define the mesothelial contribution to the tumor cell adhesion using a direct adhesion test applied to human primary cultures of mesothelial cells (HPMCs) derived from the peritoneal washes of patients with gastric and colorectal cancers. Gastric and colon carcinoma cells were seeded on different mesothelial monolayers and quantitative fluorescence analysis was performed to analyze their growth and adhesive properties. The adhesion of the cancer cells was not affected by the origin of the HPMCs when derived from patients with different cancers or with benign disease. In contrast, the high levels of ICAM1 expression and ROS production, which characterize these senescent mesothelial cells, enhanced the tumor cell adhesion. These results suggest that the mesothelial adhesive properties are dependent on the cell senescence, while are not affected by the tumor environment. The use of peritoneal washes as a source to isolate HPMCs provides a practical and reliable tool for the in vitro analysis of the mesothelial conditions affecting the peritoneal carcinomatosis.     

Observations on induced carcinosis peritonei of the guinea pig

A diethylnitrosamine-induced hepatocellular carcinoma cell suspension (line-10), injected intraperitoneally in Sewall Wright strain-2 guinea pigs, causes ascites with implantation of malignant cells on the peritoneal surface. At these sites, swelling of the mesothelial cells and simultaneous proliferation of underlying fibroblasts and capillaries are seen. When there are about four layers of malignant cells and the mesothelial lining is disrupted, papillary projections of fibroblasts with capillaries, covered by malignant cells develop. These begin to behave as a "tissue". In these areas basement membrane destruction and lymphatic and blood vessel infiltration are demonstrable. These developments have been investigated by light microscopy, histochemistry, transmission- and scanning electron microscopy.     

MicroRNA‐302c modulates peritoneal dialysis‐associated fibrosis by targeting connective tissue growth factor

Long‐term peritoneal dialysis (PD) can lead to the induction of mesothelial/epithelial‐mesenchymal transition (MMT/EMT) and fibrosis; these effects eventually result in ultrafiltration failure and the discontinuation of PD. MicroRNA‐302c (miR‐302c) is believed to be involved in regulating tumour cell growth and metastasis by suppressing MMT, but the effect of miR‐302c on MMT in the context of PD is unknown. MiR‐302c levels were measured in mesothelial cells isolated from the PD effluents of continuous ambulatory peritoneal dialysis patients. After miR‐302c overexpression using lentivirus, human peritoneal mesothelial cell line (HMrSV5) and PD mouse peritoneum were treated with TGF‐β1 or high glucose peritoneal dialysate respectively. MiR‐302c expression level and MMT‐related factors alteration were observed. In addition, fibrosis of PD mouse peritoneum was alleviated by miR‐302c overexpression. Furthermore, the expression of connective tissue growth factor (CTGF) was negatively related by miR‐302c, and LV‐miR‐302c reversed the up‐regulation of CTGF induced by TGF‐β1. These data suggest that there is a novel TGF‐β1/miR‐302c/CTGF pathway that plays a significant role in the process of MMT and fibrosis during PD. MiR‐302c might be a potential biomarker for peritoneal fibrosis and a novel therapeutic target for protection against peritoneal fibrosis in PD patients.