Traumatic Implantation: A Novel Aetiology in the Development of Peritoneal Mesothelioma

Peritoneal mesothelioma is a rare intra-abdominal malignancy. Its aetiology has been thought to be due to either inhalation or ingestion of asbestos particles. We present a case of peritoneal mesothelioma developing as a result of a novel third route and the inoculation of fibres into the peritoneal cavity by penetrating trauma and direct transport. This case report highlights the important long term consequences of penetrating abdominal trauma and the need for vigilance in undertaking peritoneal toilet. 1. Introduction Malignant mesothelioma of the peritoneum is a rare malignancy, but one that is increasing in incidence. Prognosis is poor and almost universally fatal. The untreated median survival rate is 6 months and even with the most aggressive multimodal therapy in the form of debulking or cytoreductive surgery and heated intraperitoneal chemotherapy five year survival ranges only from 29% to 59% [1, 2]. As treatment is associated with high morbidity and ultimate failure, a large amount of work is done to reduce exposure to asbestos and other nonasbestos mineral fibres such as Erionite which are implicated in the development of the disease. Typically the inhalation of fibres precedes the peritoneal inoculation and therefore it can be hoped that environmental health procedures on the handling of asbestos will start to have an effect on the incidence of peritoneal mesothelioma in the majority of cases [3]. This case would unfortunately not be effected by such measures due to the novel aetiology of inoculation of the fibres as described. 2. Case Presentation A 68-year-old male presented to the surgical outpatient department after failure of medical management of his dyspeptic symptoms. His presenting symptoms were of worsening dyspepsia, anorexia, and a small degree of weight loss. His past medical history included mild ischaemic heart disease and a previous deep vein thrombosis. The patient also described having had a laparotomy more than 20 years previously. Whilst working as a roofer, the patient had fallen from a height onto the spike of a garden parasol. The patient removed the impaling object himself and presented to the emergency department. An entry wound in the perineum was noted, washed, and closed and the patient was admitted for observation. After 48 hours with no signs of illness, he was discharged but represented two weeks later with peritonitis. At laparotomy, an abscess cavity containing pieces of clothing in the right upper quadrant was noted; no GI organs were breached or resected. On examination in clinic 20 years later, he was