The Misty Mesentery Dilemna. Kristin Greenlaw PGY4 Dalhousie University

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1 The Misty Mesentery Dilemna Kristin Greenlaw PGY4 Dalhousie University

2 Objectives Review the differential diagnosis of misty mesentery finding on CT Discuss Sclerosing Mesenteritis (SM): Etiology, Findings, Differential Follow up recommendations

3 Incidental finding, what to do Follow up or let it go?

4 Misty Mesentery A regional increase in mesenteric fat density May be caused by mesenteric infiltration of: Inflammation Neoplastic cells Fluid (edema, blood, lymph) Fibrous tissue/idiopathic Mindelzun et al., 1996

5 Fluid Mesenteric edema Heart failure Portal hypertension Cirrhosis Hemorrhage Trauma Anticoagulation Ischemic enteritis Lymphatic obstruction Neoplasm Trauma/Surgery Radiation Lymphatic malformation Imaging features - Often associated with generalized edema or ascites - Additional retroperitoneal and omental fluid

6 Inflammation Underlying pancreatitis, appendicitis, diverticulitis, and other itis TB enlarged lymph nodes with central hypodensity nodular mesentery enhancing smooth peritoneal thickening high density ascites

7 Case - Subtle mesenteric stranding, plus stranding around the gallbladder fossa - US findings consistent with cholecystitis

8 Neoplasm Non Hodgkin Lymphoma Carcinoid Metastasis Misty mesentery appearance may be caused by tumour cell infiltration, or obstruction of lymphatics

9 Idiopathic Sclerosing Mesenteritis 92% is incidental, 0.6% of all studies Can be symptomatic pain, nausea, fever, mass, obstruction Reported association with future malignancy, up to 30%, but is this a true association? Possible causes Post surgery/trauma Vasculitis Infection Autoimmune (IgG4 related condition)

10 Mesenteric Lipodystrophy Fat replaced by foamy macrophages Mesenteric stranding and mild lymphadenopathy Sclerosing Mesenteritis Mesenteric Panniculitis Infiltrate of plasma cells, PMNs, foamy macrophages Mesenteric stranding and mild lymphadenopathy Retractile Mesenteritis Collagen, fat necrosis, fibrosis Mesenteric stranding +/- soft tissue mass, mild lymphadenopathy Sclerosing mesenteritis (SM) is an overarching term, including several other pathologic diagnoses depending on the appearance and stage of disease

11 Sclerosing Mesenteritis Imaging Findings Most often involves the jujenal mesentery Oriented to the left Fat ring sign sparing of fat around vessels Tumoral pseudocapsule - <3 mm thickness, surrounding stranding Mesenteric root mass can calcify, cause mass effect However, all features are non-specific and can rarely be seen with neoplasm

12 Mesenteric lipodystrophy and mesenteric panniculitis can have a similar appearance on CT Example of: Pseudocapsule Fat ring sign Taffel et al., 2014

13 Retractile mesenteritis An example of: - Spiculated mesenteric root mass - Compression of adjacent vessels - Calcification Taffel et al., 2014

14 Differentiating Sclerosing Mesenteritis and Malignancy Sclerosing mesenteritis Compression/obstruction of structures Pseudocapsule Mildly enlarged lymph nodes +/- Calcification Carcinoid Spiculated mass with mesenteric spread Primary hyperenhancing small bowel mass Hepatic metastasis 70% calcified Lymphoma Encasement of structures Other lymph node groups enlarged Nodular If treated: infiltrative stranding, and calcification

15 Case 1 February 2014 Multiple imaging features of SM However, lymph nodes >1 cm, and multiple mildly enlarged lymph nodes in other areas (mediastinal, retroperitoneal) 6 Follow up CT suggested

16 Case 1 February 2015 Follow up CT did not occur until 1 year later Large retroperitoneal mass of conglomerate lymph nodes, and further enlargement of other nodes Pathology proven Diffuse Large B Cell Lymphoma

17 Case 2 Incidental mesenteric stranding and soft tissue nodules, measuring > 1cm. Multiple imaging features of SM.

18 March 2014 July 2014 Case 2 The mesenteric findings were similar on a follow up CT, however, a single enlarged retrocrural node is increased >1 cm. Suspicious for lymphoma!

19 Follow up Tallef et al., 2014 suggests: Soft tissue nodule >10 mm, consider biopsy, or close CT follow up If no history of malignancy and lymph nodes smaller than 5 mm - no follow up Corwin et al., 2012 found: Followed patients with imaging diagnosis of sclerosing mesenteritis for 2 years 0/30 developed lymphoma if lymph nodes <1 cm 3/7 developed lymphoma if lymph nodes >1 cm

20 Conclusions Misty mesentery finding has a wide differential Consider an inflammatory, traumatic or neoplastic etiology before labeling as sclerosing mesenteritis Suggested follow up If isolated to mesentery and lymph nodes <5 mm, no follow up required If nodes 5-10 mm consider follow up (~6 months) If nodes >10 mm consider surgical referral, biopsy or close interval follow (3-6 months)

21 References 1. Al Zahrani, H., Kyoung Kim, T., Khalili, K., Vlachou, P., Yu, H., & Jang, H.-J. (2014). IgG4-related disease in the abdomen: a great mimicker. Seminars in Ultrasound, CT, and MR, 35(3), Brooke, R., Mindelzun, R. E., Lane, J., & Silverman, P. M. (1996). The Misty Mesentry on CT : Differential Diagnosis, (July), Carruthers, M. N., Stone, J. H., & Khosroshahi, A. (2012). The latest on IgG4-RD: a rapidly emerging disease. Current Opinion in Rheumatology, 24(1), Chen, T. S., & Montgomery, E. a. (2008). Are tumefactive lesions classified as sclerosing mesenteritis a subset of IgG4- related sclerosing disorders? Journal of Clinical Pathology, 61(10), Chopra, S., Dodd, G., Kedar, C., Esola, C., Ghiastas, G. (1999). Mesenteral, Omental and Retroperitoneal Edema in Cirrhosis: FIndings and Spctrum of CT Findings. Radiology. 211: Dashkalogiannaki, Voloudaki, A., Prassopoulos, P., Magkanas, E., Apostolaki, E., & Gourtsoyiannis, N. (2000). CT Evaluation of Mesenteric Panniculitis : Prevalence and Associated Diseases, (February), George, V., Varaha, F., Tammisetti, S., Surabhi, V. R., & Shanbhogue, A. K. (2013). Chronic Fibrosing Conditions in Abdominal Imaging 1, Kipfer, R., Moertel, C., & Dahlin, D. (1974). Mesenteric Lipodystrophy. Annals of Internal Medicine McLaughlin, P. D., Filippone, A., & Maher, M. M. (2013). The misty mesentery : mesenteric panniculitis and its mimics. AJR. American Journal of Roentgenology, 200(2), W Newman, P., Thahal, H., Chaudrey, B. (2014) Mesenteric Panniculitis. BMJ Case Reports. doi: /bcr Taffel, M. T., Khati, N. J., Hai, N., Yaghmai, V., & Nikolaidis, P. (2014). De-misty-fying the mesentery: an algorithmic approach to neoplastic and non-neoplastic mesenteric abnormalities. Abdominal Imaging, 39(4), Corwin, M., Smith, A., Karam, A. & Sheiman, R. (2012). Incidentally detected misty mesentery on CT: Risk of malignancy correlated with mesenteric lymph node size. Journal of Computed Assisted Tomography, 36, 1,

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