Case Report: Can we differentiate mesothelioma from inflammatory pericardial constriction preoperatively?

Our plain-English summary of Case Report: Can we differentiate mesothelioma from inflammatory pericardial constriction preoperatively?, by S.S. Raza, I. Ullah, S.K. Awan, et al (F1000Research, 2020).

The study

• Authors: S.S. Raza, I. Ullah, S.K. Awan, M.D. Nadeem, G. Bashir
• Journal: F1000Research
• Published: 2020;9:513
• Type of article: Case report
• Read it: PubMed · Publisher · Free full text

Abstract

Primary malignant pericardial mesothelioma (PMPM) is a rare cardiac tumor. The patient usually presents with pericardial constriction, usually misdiagnosed and wrongly managed. We present the case of a 21-year-old woman with a history of pericarditis and cardiac tamponade. The patient was referred from a clinic due to nausea, vomiting and ascites with lower extremity edema, soft and watery diarrhea, and right upper quadrant pain. Surgery (sternotomy and partial pericardiectomy) was proposed after looking at the different relevant investigations; it was not until that the patient was operated on that it was established that this wasn't a mere constriction but a malignancy. The patient shortly died after the operation. Pathology made a diagnosis of PMPM. Along with the classical symptoms those who present with level 1 thoracic adenopathy a decision to operate should be very carefully made, this may lead to a misdiagnosis of PMPM which postoperatively results in patient's death.

Copyright: © 2020 Raza SS et al.

In plain English

This article is a case report about one patient. A 21-year-old woman with a past history of pericarditis and cardiac tamponade came to the authors' hospital with nausea, vomiting, fluid in the abdomen, leg swelling, diarrhoea and right upper abdominal pain. Fluid drained from around her heart earlier had shown no malignant cells. Heart scans led to a diagnosis of constrictive pericarditis with a markedly thickened pericardium (the sac around the heart). A CT scan also showed level 1 thoracic adenopathy, meaning enlarged lymph nodes in the chest. During surgery the pericardium seemed to be invading the right ventricle, and a frozen section suggested a malignant tumor. She died shortly after the operation. Final pathology showed biphasic malignant mesothelioma of the pericardium. Looking back at the heart MRI, the authors noted subtle signs of invasion into the heart muscle. The authors concluded that when classical symptoms come with level 1 thoracic adenopathy, the decision to operate should be made very carefully. The report did not describe any asbestos exposure for this patient.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: case report (single patient)
• Who was studied: One 21-year-old woman with a past history of pericarditis and cardiac tamponade. She was referred from a clinic to the Emergency Department of the authors' hospital (hospital and date not stated) with nausea, vomiting, ascites (fluid in the abdomen), lower-leg oedema, watery diarrhoea and right upper quadrant pain.
• Exposure: No asbestos or other exposure history is reported for the patient. In their discussion, the authors state that asbestos has been thought to be the cause of and linked to this disease, but that such evidence has not yet been documented in the medical literature.
• Main results:
  • Fluid drained from around the heart (pericardiocentesis), done when she was diagnosed with cardiac tamponade two months before presentation, showed no malignant cells, only mild nonspecific inflammation.
  • Before surgery, imaging (including cardiac magnetic resonance) led to a diagnosis of constrictive pericarditis with a markedly thickened pericardium.
  • CT scanning showed a markedly thickened pericardium and level 1 thoracic adenopathy.
  • During surgery, the pericardium appeared to be invading the right ventricle.
  • During surgery, a frozen section suggested a malignant tumor, possibly mesothelioma or metastatic breast cancer.
  • The patient could not be resuscitated after surgery and died shortly after the operation.
  • Final pathology of the excisional biopsy showed biphasic malignant mesothelioma, which the authors described as pericardial malignant mesothelioma (PMPM).
  • On retrospective review of the cardiac MRI, the authors noted a subtle loss of the normal boundary between heart muscle and pericardium, which suggested invasion of the heart muscle.
• The authors' conclusion: The authors concluded that in patients with the classical symptoms who also have level 1 thoracic adenopathy, the decision to operate should be made very carefully, because the condition may be a misdiagnosed PMPM that can lead to death after surgery.

Topics

Medical terms in this study, explained in our Lexicon: Mesothelioma, Pericardial, Pericardial Mesothelioma, Cardiac Tamponade, Ascites, Pericardiectomy, Pathology, Misdiagnosis.

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