Metastatic appendiceal mucinous adenocarcinoma to well-differentiated diffuse mesothelioma of the peritoneal cavity: A mimicker of florid mesothelial hyperplasia in association with neoplasms

A typical/florid mesothelial hyperplasia associated with another neoplastic process is not an infrequent phenomenon and has been reported in a variety of tumors. In those instances, the mesothelial proliferation might create a misdiagnosis of metastatic carcinoma but seldom raises the possibility of a well-differentiated mesothelioma seeded by metastatic neoplastic cells. Herein, we report the case of a 40-year-old woman originally diagnosed with exuberant atypical mesothelial hyperplasia after an diagnostic laparoscopy. The subsequent operation, however, demonstrated a mucinous neoplasm of the appendix with involvement of the peritoneal cavity in the form of peritoneal mucinous carcinomatosis as well as metastases to the uterine serosa and adnexal surfaces. Microscopic analysis revealed an appendiceal adenocarcinoma with signet-ring-cell features that has metastasized to a diffuse well-differentiated mesothelioma of the peritoneal cavity. In many areas, the atypical mesothelial proliferation is indistinguishable from florid mesothelial hyperplasia. The true nature of the mesothelial proliferation was only confirmed after extensive additional sampling, which showed unequivocal stromal invasion. To the best of our knowledge, this is the first report of a metastatic appendiceal mucinous adenocarcinoma to a well-differentiated diffuse mesothelioma of the peritoneal cavity. Although commonly associated with atypical/florid mesothelial hyperplasia, a carcinoma can rarely metastasize to well-differentiated mesothelioma, which can pose significant diagnostic difficulties because it can mimic a reactive process. This unusual case report expands the spectrum of mesothelial proliferation in conjunction with a malignant neoplasm and serves to remind pathologists that such a concomitant occurrence exists.