Diffuse Pleural Mesothelioma: A Challenge in Early Diagnosis

Our plain-English summary of Diffuse Pleural Mesothelioma: A Challenge in Early Diagnosis, by A.A. Constantin, F.D. Mihaltan, A.S. Marghescu, et al (Curēus, 2024).

The study

• Authors: A.A. Constantin, F.D. Mihaltan, A.S. Marghescu, G.A. Craciunica
• Journal: Curēus
• Published: 2024;16(12):e74998
• Type of article: Case report
• Read it: PubMed · Publisher · Free full text

Abstract

We present the clinical case of a 58-year-old female patient, a smoker with occupational exposure to respiratory toxins, who was admitted to our clinic following evaluation in an emergency department, where she was diagnosed with a moderate right pleural effusion. Upon admission, the patient exhibited respiratory symptoms, including progressive dyspnea with a moderate exertion threshold, right posterior pleuritic chest pain radiating anteriorly, occasional episodes of low-grade fever, and persistent febrile symptoms lasting approximately two weeks. In this clinical context, the diagnostic process was guided by the presence of right pleural effusion syndrome, which was refractory to conservative medical therapy. This necessitated a careful and stepwise expansion of investigations, ultimately leading to the diagnosis of malignant pleural mesothelioma. This case underscores the diagnostic challenges posed by pleural effusion, the necessity of adhering to the diagnostic algorithm, and the critical role of the multidisciplinary team. The diagnostic approach, often complex and challenging, necessitates a multidimensional strategy that integrates the correlation and synthesis of data obtained through anamnesis, alongside advanced diagnostic procedures such as pleural biopsy, which remains the gold standard. This comprehensive process is essential for formulating a diagnostic suspicion, with the final diagnosis intended to be one of exclusion.

Copyright © 2024, Constantin et al.

In plain English

This case report from Romania described one 58-year-old woman, a smoker with a 15-pack-year history, who had worked for 15 years in the tobacco industry with what the authors called occupational exposure to respiratory toxins. The report does not describe any asbestos exposure for this patient. In early 2021 she had a right pleural effusion (fluid around the lung). Drained fluid showed atypical cells suggestive of malignancy, but a first pleural biopsy was non-diagnostic, and she chose to postpone thoracoscopy. A later thoracoscopic biopsy was first read as metastatic adenocarcinoma. Immunohistochemical tests and a review by a tertiary laboratory instead identified epithelioid pleural mesothelioma. She had a quasi-total pleurectomy with removal of parts of the pericardium and diaphragm, then six cycles of cisplatin-pemetrexed, and pemetrexed maintenance until January 2023. Fluid recurred in December 2023, a new nodular lesion appeared in May 2024, and she received 50 Gy of stereotactic radiotherapy in June 2024. She also had two COVID-19 infections. The authors concluded that, guided by a multidisciplinary team, she had surpassed the survival statistics estimated in the medical literature.

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 (one patient)
• Who was studied: One 58-year-old woman, a smoker (15 pack-years) with comorbidities, treated at the authors' clinic in Bucharest, Romania, from early 2021 to mid-2024
• Exposure: 15 years of occupational exposure to unspecified 'respiratory toxins' in the tobacco industry, plus smoking (15 pack-years). No asbestos exposure is described for this patient.
• Main results:
  • First thoracentesis drained about 600 ml of exudate fluid. Cytology showed atypical cells suggestive of malignancy.
  • The first pleural biopsy was non-diagnostic.
  • The patient postponed thoracoscopy with pleural biopsy and chose watchful waiting.
  • The thoracoscopic biopsy was initially read as pleural metastasis of adenocarcinoma of unknown primary origin.
  • Immunohistochemistry, then a tertiary laboratory review, identified diffuse malignant pleural mesothelioma, epithelioid subtype with a tubular pattern.
  • Surgery was a quasi-total pleurectomy with resection of a pericardial fragment and a diaphragmatic fragment.
  • After surgery she received six cycles of cisplatin-pemetrexed and pemetrexed maintenance therapy until January 2023.
  • Imaging every 3 to 6 months over 33 months after surgery showed no local recurrence or regional extension.
  • A recurrent small to moderate right pleural effusion was found in December 2023.
  • A new nodular lesion appeared in May 2024. Stereotactic radiotherapy to a total dose of 50 Gy began in June 2024 and was well tolerated.
  • The patient had two episodes of COVID-19 (SARS-CoV-2 infection), of mild to moderate form.
• The authors' conclusion: The authors concluded that, guided by a multidisciplinary team, the patient had surpassed the survival statistics estimated in the literature. They called prolonged survival the main notable aspect of the case.

Topics

Medical terms in this study, explained in our Lexicon: Pleural Mesothelioma, Occupational Exposure, Pleural Effusion, Dyspnea, Pleuritic Chest Pain, Multidisciplinary Team, Pleural Biopsy.

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