Diagnosis and management of pleural mesothelioma: three unique cases and review of the literature

Our plain-English summary of Diagnosis and management of pleural mesothelioma: three unique cases and review of the literature, by Z. Al Achkar, D. Gaspard, M. Iskandar (BMC Pulmonary Medicine, 2026).

The study

• Authors: Z. Al Achkar, D. Gaspard, M. Iskandar
• Journal: BMC Pulmonary Medicine
• Published: 2026;26(1)
• Type of article: Case report, Review
• Read it: PubMed · Publisher · Free full text

Abstract

BACKGROUND: Mesothelioma is a rare pleural tumor. Compared to diffuse pleural mesothelioma, localized pleural mesothelioma carries a better prognosis and may be managed with surgical resection. Among histologic subtypes, the sarcomatoid variant is the least common but is associated with the poorest outcome. Diagnosis remains challenging, with immunohistochemistry playing a central role in confirming the disease. While surgical resection is the cornerstone of management, chemotherapy, immunotherapy and radiotherapy are considered in unresectable cases. Overall, mesothelioma continues to carry a poor prognosis. CASE PRESENTATION: We describe three cases of pleural mesothelioma that posed diagnostic and therapeutic challenges. The first case involved a rapidly progressive sarcomatoid mesothelioma, initially raising concern for Ewing’s sarcoma, which was excluded based on negative immunohistochemical markers. The second case was an epithelioid mesothelioma successfully treated with extrapleural pneumonectomy followed by adjuvant chemotherapy and immunotherapy, resulting in prolonged survival. The third case, the only one with documented asbestos exposure, represents the first reported instance of synchronous epithelioid mesothelioma and invasive ductal carcinoma of the breast. CONCLUSION: Mesothelioma is a rare and complex pleural malignancy that may present in atypical ways, complicating both diagnosis and management. These cases underscore the importance of immunohistochemical profiling, highlight the value of multidisciplinary diagnostic approaches, and reaffirm the pivotal role of surgery within the therapeutic algorithm.

In plain English

This article reports three patients with pleural mesothelioma and discusses published literature. The first, a 58-year-old man who had never smoked and had no evident asbestos exposure, had a large chest mass that was first treated as Ewing's sarcoma. Repeat biopsies and further testing excluded Ewing sarcoma and confirmed sarcomatoid mesothelioma. Surgery was not possible, and the disease progressed on immunotherapy. He was switched to chemotherapy and died a couple of months later from septic shock and multiorgan failure. The second, a 67-year-old former smoker with no known asbestos exposure, had epithelioid mesothelioma treated by extrapleural pneumonectomy and then chemotherapy. After a local recurrence he received immunotherapy, and his partial response had lasted four years. The third, a 61-year-old woman and heavy smoker with 20 years of environmental asbestos exposure from living near an Eternit factory in Lebanon, was diagnosed with epithelioid mesothelioma and breast cancer (invasive ductal carcinoma) at the same time. She was entering her fifth year of treatment. The authors concluded that mesothelioma should be considered even without known asbestos exposure.

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 series of three patients with a narrative review of the literature
• Who was studied: Three patients with pleural mesothelioma: a 58-year-old man, a 67-year-old man and a 61-year-old woman. The authors are from Lebanese American University Medical Center hospitals in Beirut, Lebanon. The second patient presented in December 2020.
• Exposure: Only the third patient had documented asbestos exposure: 20 years of environmental exposure from living in a region of Lebanon near an Eternit factory that formerly made asbestos-reinforced fiber-cement pipes. No fiber type is named. The first two patients had no identified asbestos exposure.
• Main results:
  • Case 1 (58-year-old man, no evident asbestos exposure): Ewing sarcoma was excluded by further testing, and localized pleural sarcomatoid mesothelioma was confirmed.
  • Case 1: the cancer progressed after two cycles of nivolumab and ipilimumab. Treatment was switched to carboplatin, pemetrexed and bevacizumab, and the patient died a couple of months later of septic shock and multiorgan failure.
  • Case 2 (67-year-old man, no known asbestos exposure): epithelioid mesothelioma was treated with extrapleural pneumonectomy followed by chemotherapy (carboplatin, bevacizumab and pemetrexed).
  • Case 2: follow-up imaging showed a local recurrence. On nivolumab and ipilimumab the patient had a partial response, which had been maintained for four years.
  • Case 3 (61-year-old woman, 20 years of environmental asbestos exposure): epithelioid mesothelioma and invasive ductal carcinoma of the breast were diagnosed at the same time.
  • Case 3: the disease progressed after 31 cycles of nivolumab and ipilimumab. On carboplatin and pemetrexed she had a partial response and then stable disease, and she was entering her fifth year of treatment.
  • The marker WT-1 was positive in all three patients' tumors.
• The authors' conclusion: The authors concluded that mesothelioma should be considered when clinical and imaging findings suggest it, even without known asbestos exposure, because of the long latency period and the possibility of unrecognized exposure. They also stated that VATS biopsy has the highest diagnostic yield. In the article's body they described the third patient as, to their knowledge, the second reported case of synchronous epithelioid pleural mesothelioma and breast carcinoma.

Topics

The National Library of Medicine indexes this study under subjects our site covers: Lung cancer, Mesothelioma.

Medical terms in this study, explained in our Lexicon: Pleural Mesothelioma, Mesothelioma, Prognosis, Surgical Resection, Histological Subtype, Sarcomatoid, Immunohistochemistry, Chemotherapy.

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