|Year : 2013 | Volume
| Issue : 1 | Page : 31-34
Pattern of mesenteric nodules in the University of Benin Teaching Hospital
Ezekiel Enoghama Ugiagbe, Mojisola Olutayo Udoh
Department of Histopathology, University of Benin Teaching Hospital, Benin City, Nigeria
|Date of Web Publication||19-Apr-2014|
Ezekiel Enoghama Ugiagbe
Department of Histopathology, University of Benin Teaching Hospital, Benin City
Source of Support: None, Conflict of Interest: None
Background: The determination of the nature of mesenteric nodules and the possible identification of the primary site of metastatic neoplasm is imperative as this defines both prognosis and future management of the patients. Aims: This study is aimed at evaluating the pattern of mesenteric nodules in the University of Benin Teaching Hospital, Benin City, Nigeria. Setting: The University of Benin Teaching Hospital, between January 2005 and December 2011. Design: A descriptive retrospective study. Materials and Methods: The appropriate data were obtained from the surgical day book of the department of histopathology. The data were analyzed to reflect age, sex, pathological diagnosis, and site of the lesions. Statistical analysis used: Statistical analysis was done using the SPSS version 16 statistical package. Results: A total of 65 cases of mesenteric nodule biopsies were reported during the 7-year period. There were 34 males and 31 females with a male:female ratio of 1.1:1. The age ranged from 4 to 78 years with a mean age of 52.1 ± 13.8 years. The highest incidence was in the 6th decade. Seventy-one percent of the cases were metastatic lesions and 29% were infectious and inflammatory lesions. Of the metastatic lesions, 87% were carcinomas [adenocarcinomas constituted 97.5%], 4.3% were sarcomas, and 8.7% were lymphomas. Of the infectious and inflammatory lesions, 89.5% were nonspecific reactive lymph node hyperplasia and 10.5% were tuberculosis. Thirty-three percent of the metastatic lesions were of gastrointestinal origin, 20% of ovarian origin and 9.2% of unknown primary site. Conclusion: The preponderance of adenocarcinomas in metastatic nodules is similar to those already established in the literature with the gastrointestinal tract and the ovary been the most common sites of origin. Specialized ancillary technique like immunuhistochemistry is highly coveted to confirm the characterization and identification of the site of origin of metastatic mesenteric neoplasms.
Keywords: Gastrointestinal tract and ovary, mesenteric nodule, metastatic adenocarcinomas
|How to cite this article:|
Ugiagbe EE, Udoh MO. Pattern of mesenteric nodules in the University of Benin Teaching Hospital. Afr J Med Health Sci 2013;12:31-4
|How to cite this URL:|
Ugiagbe EE, Udoh MO. Pattern of mesenteric nodules in the University of Benin Teaching Hospital. Afr J Med Health Sci [serial online] 2013 [cited 2019 Mar 26];12:31-4. Available from: http://www.ajmhs.org/text.asp?2013/12/1/31/129920
| Introduction|| |
Tumor and tumor like lesions that secondarily involve the mesentery are a diverse group of disorders that range in biological behavior from benign to highly malignant neoplasms.  The pathological process that may secondarily affect the mesentery can be loosely categorized into three broad groups; metastatic neoplasms, infectious and inflammatory lesions, and tumor-like lesions. Metastatic disease especially from carcinomas of the gastrointestinal tract and ovary is the most common malignant process in the peritoneal cavity.  In most patients with cancer, the organ in which the malignancy developed is readily apparent. However, some patients present with cancer that has metastasized and the primary tumor site cannot be identified.  Metastatic disease of unknown primary sites is also known as cancer of unknown primary site (CUP), represents a group of heterogeneous cancers which is defined by the presence of metastatic disease without an identifiable primary tumor site on presentation. It represents 2-5% of all cancers, although the incidence can vary depending on the definition used and the extent of investigation performed. However, earlier reports have shown an incidence of 10-15%. ,, Identification of the primary sites of metastatic tumor has both therapeutic and prognostic value in patient management. ,
About 60% of CUP is adenocarcinomas, which are easily recognizable by light microscopic examination.  The common adenocarcinomas arise from the lungs, colon, breast, prostate, ovary, and pancreas. The appearance of these lesions from various sites is similar making identification of primary sites on H&E examination alone difficult. Squamous cell carcinoma is easily recognizable in additional 5%. Rare cases of melanoma and various sarcomas are readily identifiable on light microscopic examination. The remaining 35% of cases provide less specific information about tumor lineage, and for these cases the broad diagnosis is usually that of poorly differentiated neoplasms. ,
Retrospective series suggest that conventional light microscopy alone can result in a correct determination of the tumor type in approximately two-thirds of patients with CUP. Tumors without clear histological differentiation may require more sophisticated pathological techniques, such as immunohistochemistry (IHC), electron microscopy, and molecular genetic studies to determine tumor lineage. IHC is the most available adjunctive tool for classifying cancer, and it is useful in defining tumor lineage and sometimes in identifying a primary site. [2.7]
In Nigeria, as in most other developing countries, facilities for more specialized pathological techniques are rarely available and where available they are not routinely used. Most cancer cases in our environment present at advanced stages with mesenteric (peritoneal) metastasis, and the only available option is to obtain a biopsy specimen from the metastatic nodule.  The characterization of such tumor and identification of a possible primary site is necessary for optimal management of such cases. 
The aim of this study is to establish a preliminary data on the histological pattern of mesenteric nodules in the University of Benin Teaching Hospital and to provide a baseline on which more specialized techniques like immunohistochemistry could be carried out in the future when it becomes routinely available.
| Materials and Methods|| |
All mesenteric nodule biopsies received at the Department of Pathology, University of Benin Teaching Hospital, Benin City, Nigeria, from January 2005 - December 2011 were reviewed and formed the basis for this study.
University of Benin Teaching Hospital, Benin City, Edo State is located in the South - South region of Nigeria and caters for the health needs of patients in this geo-political zone with a population of over 10 million people. Clinical and demographic data regarding age, sex, and clinical information were obtained from request cards and the surgical day books of the department. Slides were retrieved from the archives of the department and when necessary, new slides were made from formalin fixed, paraffin embedded blocks and used for the histological diagnosis and determination of the primary site of metastatic malignant neoplasms.
Statistical analysis was done using the SPSS version 16 statistical package.
| Results|| |
During the 7-year period, there were 65 cases of reported mesenteric nodule biopsies at the University of Benin Teaching Hospital. There were 34 males and 31 females with a male:female ratio of 1.1:1. The age ranged from 4 to 78 years with a mean age of 52.1 ± 13.8. The highest incidence was in the 6th decade, as shown in [Table 1].
There were two broad groups of histopathological diagnoses, and these included 46 (71%) cases of metastatic malignant lesions, 19(29%) cases of infectious and inflammatory lesions and no case of tumor-like lesion was seen. Of the metastatic cancers, 87% (40/46) of cases were carcinomas, 4.3% (2/46) were sarcomas, and 8.7% (4/46) were lymphomas. Most of the infectious cases, 89.5% (17/19), were non-specific reactive hyperplasia of the mesenteric lymph nodes and 10.5% (2/19) were Tuberculosis. Majority of the metastatic carcinomas were adenocarinomas (39/40), with a single case of squamous cell carcinoma. The four cases of lymphoma seen were composed of two cases each of Non-Hodgkins and Hodgkins lymphomas. The two cases of sarcomas were a single case each of pleomorphic sarcoma and granulosa cell tumor as shown in [Table 2].
This study showed that most of the cases, 35.4% (23/65) primarily involved the lymph node, with 19 infectious/inflammatory cases, and 4 cases of lymphoma. Twenty-one (32.3%) cases had enough morphologic features to show that they were gastrointestinal in origin, 13 (20%) cases of ovarian origin and 1(1.5%) case each from the pancreas and endometrium. Six (9.2%) cases lacked any morphologic features to determine their primary organ of origin as shown in [Table 3].
Metastatic neoplasm involving the mesentery is a devastating diagnosis as it is seldom curable and most of the current surgical and medical treatments are only palliative. Intraperitoneal dissemination of tumor cells occurs by several mechanisms; intraperitoneal seeding, direct invasion, or lymphohematogenous spread. Mesentaric seeding occurs most commonly from gastrointestinal and ovarian malignancies as a consequence of intramural tumor growth with extension through the bowel wall or peritoneal lining of the ovary. ,
This study showed a 71% incidence of metastatic neoplasms, which is similar to previous report from other parts of the world, where secondary tumors of the peritoneum have been reported to be quite common in contrast to primary peritoneal tumors that are rare. , Majority of these metastatic lesions (87%) were carcinomas, with 4.3 and 8.7%, respectively, of sarcomas and lymphomas. Thirty-nine out of the forty cases (97.5%) metastatic carcinomas were adenocarcinomas which is similar to previous report from Lagos, Nigeria, where all the metastatic carcinomas were adenocarcinomas, thus corroborating previous studies which recorded that adenocarcinoma accounted for over 60% of all metastatic neoplasms. ,
The common primary sites of metastatic carcinomas include: gastrointestinal tract, ovary, lungs, pancreas, breast, and prostate. , This study showed that 21(32.3%) cases had enough morphologic features to show that they were of gastrointestinal origin, 13 (20%) cases of ovarian origin and 1(1.5%) case each from the pancreas and endometrium. Thus, the preponderance of gastrointestinal metastasis to the mesentery has further been confirmed by this study, which is similar to previous report from Lagos, Nigeria.  Malignant neoplasms of ovarian origin was less common as it accounted for 20% of metastatic cases, which is similar to previous report, but in contrast to some other studies, where the ovaries have been indicated as the commonest primary site. ,,,
Other malignancies such as the lymphomas and the sarcomas were not a very common finding in this study as they occurred only in 4(6.2%) and 2(3.1%) cases, respectively. Six (9.2%) cases lacked any morphologic features to determine their primary organ of origin. These are cases that could have benefited from a more specialized technique such as immunohistochemistry. The clinical importance of determination of site of origin of metastatic tumors cannot be overemphasized, especially in our environment where patients present with advanced stages of the disease. , More so as the knowledge of the primary site determines not only the therapeutic approach to these patients but also the prognosis. ,
The age distribution of metastatic neoplasm in this study showed preponderance in the 6th decade, accounting for 30.8% of the study population. This is not surprising as most malignancies involving the major primary sites (gastrointestinal tract and ovary) as seen in this study have a peak age about the 6 th decade of life. Patients with metastatic carcinomas of gastrointestinal origin had a peak age incidence in the 50-69 year age group which is similar to previous studies. , In the same vein, lesions of ovarian origin had a peak age incidence of 50-59 years, which is in tandem with similar studies in the US. 
This study showed a 29% incidence of infectious and inflammatory lesions. Only two of these cases had enough morphological features of tuberculosis and the other 17 cases were those of non-specific lymph node reactive hyperplasia. The many cases of non-specific hyperplasia seen in this study may not be unrelated to the recurrent subclinical bacterial infections prevalent in many developing countries, , Several infectious and inflammatory conditions, such as atypical mycobacterial infection and tuberculosis, other inflammatory conditions and vascular abnormalities produce mesenteric nodal enlargement that mimics lymphomas and metastasis. The rising prevalence of abdominal atypical mycobacterial infection and the reemergence of tuberculosis can be attributed to the increasing number of immunocompromised hosts, particularly patients infected with human immunodeficiency virus, those on chronic steroid therapy and intravenous drug users. Enlarged mesenteric lymph nodes can also be seen in some noninfectious inflammatory conditions, such as celiac sprue, Crohn's disease, systemic mastocytosis, sarcoidosis, and rare cases of mesenteric castleman's disease. ,
In conclusion, this study has further confirmed previous studies that adenocarcinomas are the most common metastatic tumors to the mesentery and the common primary sites are the gastrointestinal tract and ovary. Also the common finding of reactive lymph node hyperplasia points to the high prevalence of subclinical microbial infection in our environment. The use of specialized ancillary techniques particularly immunohistochemistry is highly desirable and recommended in our tertiary health institutions to help characterize and identify the site of origin of mesenteric metastasis before initiating specific treatment.
| Acknowledgements|| |
We are very grateful to the General Surgeons of the departments of Surgery who provided majority of the samples used in this study and the staff of the histopathology laboratory for the bench work.
| References|| |
|1.||Levy AD, Shaw JC, Sobin LH. Secondary tumours and tumour lile lesions of the peritoneal cavity: Imaging features with pathologic correlation. RadioGraphics 2009;29:347-73. |
|2.||Dowell JE. Cancer from an unknown primary site. Am J Med Sci 2003;326:35-46. |
|3.||Abdulkareem FB, Rotami O. Immunophenotypical categorization of omental and liver metastatic tumours in Lagos, Nigeria. Nig Q J Hosp Med 2008;18:198-201. |
|4.||Varadhachary GR, Abbruzzese JL, Lenzi R. Diagnostic strategies for unknown primary cancer. Cancer 2004;100:1776-85. |
|5.||Hewitt MJ, Anderson K, Hall GD, Weston M, Hutson R, Wilkinson N, et al. Women with peritoneal carcinomatosis of unknown origin: Efficacy of image guided biopsy to determine site specific diagnosis. BJOG 2007; 114:46-50. |
|6.||Hainsworth JD, Greco FA. Treatment of patients with cancer of unknown primary site. N Engl J Med 1993;329:257-63. |
|7.||Hainsworth JD, Wright EP, Johnson DH, Davis BW, Greco FA. Poorly differentiated carcinoma of unknown primary site: Clinical usefulness of immunoperoxidase staining. J Clin Oncol 1991;9:1931-8. |
|8.||Smith S, Rajagopal KV. CT mimics of peritoneal carcinomatosis. Indian J Radiol Imaging 2010;20:58-60. |
|9.||Turner JR. The gastrointestinal tract. In: Kumar V, Abbas AK, Fausto N, Aster JC, editors. Robbins Pathologic Basis of Disease, 8 th ed. Philadelphia: WB. Saunders Co.; 2010. p. 763-832. |
|10.||Sheth S, Horton KM, Garland MR, Fishman EK. Mesenteric neoplasm: CT appearance of primary and secomndary tumours and differential diagnosis. RadioGraphics 2003;23:457-73. |
|11.||Hammar SP. Metastatic adenocarcinoma of unknown primary origin. Human Pathol 1998;29:1393-402. |
|12.||Peritoneum, retroperitoneum and related structures. In: Rosai and Ackerman's Surgical Pathology, 9 th ed. USA: CV Mosby Company; 2004. p. 2373-415. |
|13.||Anderson RN, Minino AM, Hoyet DL, Rosenberg HM. Comparability of causes of death between ICD-9 and ICD-10: Preliminary estimates. Natl Vital Stat Rep 2001;49:1-32. |
|14.||Jemal A, Thomas A, Murray T, Thun M. Cancer statistics, 2002. CA Cancer J Clin 2002;52:23-47. |
|15.||Ellenson LH, Pirog EC. The female genital tract. In: Kumar V, Abbas AK, Fausto N, Aster JC, editors. Robbins Pathologic Basis of Disease, 8 th ed. Philadelphia: WB. Saunders Co.; 2010. p. 1005-64. |
|16.||Osifo OD, Ugiagbe EE. Lymph node biopsy for histopathologic diagnosis in infant and children. Niger J Surg Sci 2010;20:28-52. |
|17.||Ojo BA, Buhari MO, Malami SA, Abdulrahaman MB. Surgical lymph node biopsies in University of Ilorin Teaching Hospital, Ilorin, Nigeria. Niger Postgrad Med J 2005;12:299-304. |
[Table 1], [Table 2], [Table 3]