A rare look into the rarest forms of cancer: mesothelioma of the liver
Last month, a new case report was released detailing the imaging features of one of the rarest of cancers in its most rare anatomic location: mesothelioma of the liver. Only 20 cases of this cancer ever have been reported worldwide.
The manuscript by Li G, Hong S, He T, Xu J. Case Report: Whispers of the serpent: exploring uncommon imaging features in primary hepatic malignant mesothelioma. Front Med (Lausanne). 2025 Nov 12;12:1713971. doi: 10.3389/fmed.2025.1713971. PMID: 41312465; PMCID: PMC12647047 can be found in its entirety here: https://pmc.ncbi.nlm.nih.gov/articles/PMC12647047/
Primary Mesothelioma of the Liver? How is That Possible?
Mesothelioma is a rare cancer that develops from the mesothelial cells which make up the lining that surrounds the lungs, the peritoneum, heart and the testes. Typically, such a lining is meant to provide the organs it surrounds with a slippery and protective surface. The pleura gives name to pleural mesothelioma which is the most commonly occurring type of this cancer. The peritoneum is the lining surrounding the abdominal area, hence the name peritoneal mesothelioma for the malignancy arising from it. Following a similar naming pattern, the pericardium gives name to pericardial mesothelioma which affects the lining surrounding the heart, and mesothelioma of the tunica vaginalis is named after the lining that surrounds testicular tissue.
But the liver is not surrounded by mesothelial tissue, or is it?
The liver is protected by a layer of fibrous connective tissue called the Glisson’s capsule. This layer allows for exchange of fluids as well as cells, and due to embedded nociceptors, when stretched or damaged, it triggers the sensation of pain. However, the outermost layer of the liver’s capsule is lined by a very thin layer of mesothelial cells arising from the peritoneum. And occasionally, medical professionals theorize, pockets of those mesothelial cells can go on to develop malignant mesothelioma.
Case Report
Due to the extreme rarity of mesothelioma on the liver, the authors of the manuscript described imaging features identified throughout the diagnosis process for their patient. The patient, a 66-year-old male, presented with tenderness in the right upper quadrant and was initially misdiagnosed with a liver abscess. During a follow-up visit 3-months later, the CT confirmed that the hepatic mass had not decreased or resolved. The patient, in conjunction with his care team, opted for a surgical removal of the tumor. Postoperative histopathology confirmed the tumor to be an epithelioid primary hepatic malignant mesothelioma (PHMM).
The authors acknowledge that pre-operative diagnosis of PHMM will continue to pose significant challenges, but they point out the imaging characteristics that might be helpful in giving clinicians a clue: a serpiginous peripheral enhancement pattern visible on contrast-enhanced CT scan, which is not usual in hepatic tumors, but that has already been reported in previous cases of PHMM.
In the last 5 years, 9 cases of PHMM have been reported. Of those, 5 patients were female, and the median age was 65. In six patients, the tumors were of the epithelioid type, two were sarcomatoid, and one was biphasic. Currently, there is no standard of care for this type of mesothelioma and the patient in the case report received no adjuvant therapy. Three-months post-surgery, the patient is doing well with no recurrence.
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