Table of Contents  
CASE REPORT
Year : 2014  |  Volume : 7  |  Issue : 4  |  Page : 516-518  

Nodular mesenteric panniculitis of rectum simulating malignancy


1 Department of Pathology, T N Medical College and B Y L Nair Hospital, Mumbai, Maharashtra, India
2 Department of Surgery, T N Medical College and B Y L Nair Hospital, Mumbai, Maharashtra, India

Date of Web Publication25-Jun-2014

Correspondence Address:
Manish Patil
31/610, Samata Nagar, Kandivali East, Mumbai - 400 101, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-2870.135295

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  Abstract 

Mesenteric panniculitis is a benign fibroinflammatory process involving adipose tissue of the mesentery. We report a case of a 62 year old male who showed signs of partial bowel obstruction and whose computed tomography of abdomen showed nodular soft tissue densities around the sigmoid junction. Distal colectomy was planned and laparotomy was performed. Anal skin, rectum and sigmoid colon was resected. Microscopic pathologic sections from the serosal nodule showed histo morphologic features of panniculitis while overlying mucosa showed tumor consisting of mucin secreting adenocarcinoma.

Keywords: Mesenteric, panniculitis, nodular


How to cite this article:
Amarapurkar A, Patil M, Shah V, Chaphekar A. Nodular mesenteric panniculitis of rectum simulating malignancy. Med J DY Patil Univ 2014;7:516-8

How to cite this URL:
Amarapurkar A, Patil M, Shah V, Chaphekar A. Nodular mesenteric panniculitis of rectum simulating malignancy. Med J DY Patil Univ [serial online] 2014 [cited 2021 Oct 19];7:516-8. Available from: https://www.mjdrdypu.org/text.asp?2014/7/4/516/135295


  Introduction Top


Mesenteric panniculitis (MP) of the rectum is a rare occurrence in surgical practice. MP is a benign fibro-inflammatory process involving adipose tissue of the mesentery characterized by the presence of fat necrosis, chronic inflammation and fibrosis, when localized, it mimics malignancy.We present a rare case of nodular mesenteric panniculitis associated with carcinoma of rectum.


  Case Report Top


A 62-year-old male was admitted to our hospital with history of generalized weakness, intermittent left lower quadrant abdominal pain, weight loss, constipation, and signs of partial bowel obstruction for last 6 months. There was no history of fever, malena, or mucus in stools. Physical examination revealed a palpable tender mass in the left abdomen. The patient gave history of fistulectomy operation done 4 years ago.

Computed tomography of abdomen done in other institute showed nodular soft tissue densities around the sigmoid junction. Routine laboratory findings were within normal limits. The tumor markers CEA and CA 19.9 were within the normal range. Considering biopsy diagnosis of adenocarcinoma, possibility of tumor invading into attached (overlying) mesentery was considered. Distal colectomy was planned and laparotomy was performed. Anal skin, rectum, and sigmoid colon were resected and sent for histopathological examination.

Histopathological examination:

Grossly, a segment of distal colon was received measuring 10 cm. On serosal aspect, overlying recto-sigmoid junction, a well demarcated single nodular lesion was seen measuring 4 × 4 cm 2 . The cut surface was yellowish white, firm with few congested areas. The overlying mucosa over the nodule was firm and flattened. Rest of the mucosa and bowel wall, adjacent to mass was normal [Figure 1].
Figure 1: Gross of surgical specimen shows 4 cm nodule in the mesentery with characteristic intensely yellow areas with congestion

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Microscopic pathologic sections from the serosal nodule demonstrated chronic reactive inflammatory process with proliferation of fibroblasts in the adipose tissue. Areas of steatonecrosis and lipid laden macrophages, few giant cells, [Figure 2] lymphocytes and plasma cells were present. [Figure 3] Based on these characteristic features, diagnosis of mesenteric panniculitis was given. Sections from the firm overlying mucosa showed tumor consisting of mucin secreting adenocarcinoma infiltrating upto superficial layer of muscularispropria [Figure 4].
Figure 2: Section from nodule shows adipose tissue infiltrated by lymphocytes, plasma cells, and large number of lipophages associated with moderate fibrosis

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Figure 3: High power view of the nodule highlights lipophages and few giant cells

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Figure 4: Section shows rectal adenocarcinoma (arrow). Serosa shows nodular panniculitis without involvement of muscle layer

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  Discussion Top


Mesenteric panniculitis is more common in men, with a male/female ratio of 2-3/1, and the incidence increases with age. [1],[2],[3] MP affects predominantly the mesentery of small intestine. [3],[4] The process rarely involves large intestine. [5] According to Wexner and Attiyeh, [6] there have been 122 cases of MP described in the literature and only three involved the mesentery of colon, and they reported two cases of MP of sigmoid colon. According to literature review of Karentzos and co-workers [7] in 1990, only 5 of 124 cases of MP involved mesentery of sigmoid colon. Emory and co-workers [8] reviewed 84 cases coded as mesenteric lipodystrophy, mesenteric panniculitis, retractile mesenteritis, and sclerosingmesenteritis. The authors suggest that numerous terminologies appear to represent histologic variants of one clinical entity. The most consistent histologic findings in that study were the presence of fibrosis and chronic inflammatory infiltrate as was demonstrated in our case.

Nodular mesenteric panniculitis can be mistaken for a mesenteric neoplasm based on clinical, radiological, and gross characteristics. [5] The standard diagnostic methods are not helpful in establishing the diagnosis. Only gross and microscopic examination of the surgically removed specimen clarified the diagnosis. Microscopically, inflammatory involvement of the adipose tissue shows lymphocytes, plasma cells, foam cells and giant cells and variable amount of fibrosis.Macrophages that have ingested fat, also called lipophages, are the hallmark of the diagnosis.

The aetiology and pathogenesis of the disease are very obscure. Various factors such as blunt abdominal trauma or prior surgery, infection, ischemia, auto immune processes, underlying malignancy have been suggested as possible causes. The possible aetiology in our case may be related to past surgery done for fistulectomy which was responsible for collection of inflammatory cells, foamy macrophages, and development of nodular panniculitis. Although significant number of case reports an association of MP with lymphoma, [9],[10],[11] there are few cases of MP occurring concurrently with colorectal cancer and diverticulosis. [9] Daskalogiankiet al., [12] have reported the co-existence of MP and various neoplastic diseases, especially lymphoma and gastrointestinal and urogenital adenocarcinomas of patients with MP.Association of MP and malignancy is indicated in the literature with 30% of patients with MP having an underlying malignancy. [8],[11],[13],[14],[15],[16] There is no specific treatment for MP. Current data indicate that the condition is non-progressive and presents no significant danger to the patient. [17] The differential diagnosis of mesenteric panniculitis is given in [Table 1].
Table 1: Differential diagnosis of mesenteric panniculitis

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  Conclusion Top


MP of rectum is extremely rare clinical entity. Although MP is frequently concurrent with malignancy, it is a benign condition in which normal architecture of mesentery is replaced by fibrosis, necrosis and chronic inflammatory cells. On gross examination, the alterations may be mistaken for a neoplastic process. A frozen section (histopathology) may be necessary for confirmation of the diagnosis. When the advanced inflammatory changes become irreversible and bowel obstruction occurs, resection may be indicated.A better knowledge of its clinical and radiological features could avoid unnecessary digestive resection.

 
  References Top

1.Akram S, Pardi DS, Schaffner JA, Smyrk TC. Sclerosingmesenteritis: Clinical features, treatment, and outcome in ninetytwo patients. Clin Gastroenterol Hepatol 2007;5:589-96.  Back to cited text no. 1
    
2.Ferrari TC, Couto CM, Vilaça TS, Xavier MA, Faria LC. An unusual presentation of mesenteric panniculitis. Clinics (Sao Paulo) 2008;63:843-4.  Back to cited text no. 2
    
3.Issa I, Baydoun H. Mesenteric panniculitis: Various presentations and treatment regimens. World J Gastroenterol 2009;15:3827-30.  Back to cited text no. 3
    
4.Popkharitov AI, Chomov GN. Mesenteric panniculitis of the sigmoid colon: A case report and review of the literature.J Med Case Rep2007;1:108.  Back to cited text no. 4
    
5.McCrystal DJ, O'Loughlin BS, Samaratunga H - Mesenteric panniculitis:A mimic of malignancy. Aust NZJSurg1998;68:237-9.  Back to cited text no. 5
    
6.Wexner SD, Attiyeh FF. Mesenteric panniculitis of the sigmoid colon. Report of two cases. Dis Colon Rectum 1987;30:812-5.  Back to cited text no. 6
    
7.Karentzos S, Tzoutzos D, Stravropoulas D, Giannakou N, Gkiconti I, Giannakakis A.Mesenteric panniculitis of the sigmoid. A case report and review of the literature. Minerva Chir 1990;45:1403-6.  Back to cited text no. 7
    
8.Emory TS, Monihan JM, Carr NJ, Sobin LH. Sclerosingmesenteritis, mesenteric panniculitis and mesenteric lipodystrophy: A single entity? Am J SurgPathol 1997;21:392-8.  Back to cited text no. 8
    
9.Bak M. Nodular intra-abdominal panniculitis: An accompaniment of colorectal carcinoma and diverticular disease. Histopathology 1996;27:21-7.  Back to cited text no. 9
    
10.Delgado Plasencia L, Rodríguez Ballester L, López-TomassettiFernández EM, Hernández Morales A, C`arrillo Pallarés A, Hernández Siverio N. Mesenteric panniculitis: Experience in our center. Rev EspEnferm Dig2007;99:291-7.  Back to cited text no. 10
    
11.Béchade D, Durand X, Desramé J, Rambelo A, Corberand D, Baranger B,et al. Etiologic spectrum of mesenteric panniculitis: Report of 7 cases. Rev Med Interne 2007;28:289-95.  Back to cited text no. 11
    
12.Daskalogiannaki M, Voloudaki A, Prassopoulos P, Magkanas E, Stefanaki K, Apostolaki E,et al. CT evaluation of mesenteric panniculitis: Prevalence and associated diseases. AJR Am J Roentgenol 2000;174:427-31.  Back to cited text no. 12
    
13.Hiridis S, Hadgigeorgiou R, Karakitsos D, Karabinis A. Sclerosingmesenteritis affecting the small and the large intestine in a male patient with non-Hodgkin lymphoma: A case presentation and review of the literature. J Med Case Rep2008;2:388.  Back to cited text no. 13
    
14.Goh J, Otridge B, Brady H, Breatnach E, Dervan P, MacMathuna P.Aggressive multiple myeloma presenting as mesenteric panniculitis. Am J Gastroenterol 2001;96:238-41.  Back to cited text no. 14
    
15.Kipfer RE, Moertel CG, Dahlin DC.Mesenteric lipodystrophy. Ann Intern Med 1974;80:582-8.  Back to cited text no. 15
    
16.Harris RJ, Van Stolk RU, Church JM, Kavuru MS.Thoracic mesothelioma associated with abdominal mesenteric panniculitis. Am J Gastroenterol 1994;89:2240-2.  Back to cited text no. 16
    
17.Duman M, Kocak O, Fazli O, Kocak C,Atici AE, Duman U.Mesenteric panniculitis patients requiring emergency surgery: Report of three cases. Turk J Gastroenterol 2012;23:181-4.  Back to cited text no. 17
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1]



 

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