Malignant pleural mesothelioma presenting with remitting-relapsing pleural effusions: report of two cases

Our plain-English summary of Malignant pleural mesothelioma presenting with remitting-relapsing pleural effusions: report of two cases, by S. Muruganandan, D.B. Fitzgerald, Y.C.G. Lee (Respirology Case Reports, 2018).

The study

• Authors: S. Muruganandan, D.B. Fitzgerald, Y.C.G. Lee
• Journal: Respirology Case Reports
• Published: 2018;6(3):e00306
• Type of article: Case report
• Cited by: 2 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Pleural effusions are common and are associated with malignancy in one sixth of cases. Malignant pleural effusion (MPE) is typically persistent and progressive, prompting further investigations if the initial tests are not diagnostic. A spontaneously remitting effusion is commonly presumed to be benign, and further investigations may not be performed. We present two cases in which the presenting pleural effusion spontaneously resolved but recurred (in one case, multiple times), leading to further investigations that revealed an underlying malignant pleural epithelioid mesothelioma. These cases demonstrate the need for clinicians to be aware that remitting effusions can occur in the context of pleural malignancy and should be kept under observation, with a low threshold for further investigation if relapse occurs.

In plain English

This case report described two men in Perth, Australia, whose fluid around the lung (pleural effusion) shrank or largely cleared unaided, then returned. Both were eventually diagnosed with malignant pleural epithelioid mesothelioma. The first, a 63-year-old carpenter exposed to asbestos, had lived three childhood years in an asbestos mining town. His left-sided effusion largely cleared within 2 weeks, then returned and cleared twice more over 4 months. Keyhole surgery (VATS) found abnormal pleura among pleural plaques; a biopsy showed mesothelioma. The second, 78, installed refrigerators and air-conditioning units, drilling through asbestos walls and roofs. His effusion shrank within 2 days, leaving a small residual effusion; fluid testing found no evidence of cancer. Two months later it had returned, and a biopsy then showed benign fibrinous pleuritis. Six months further on it persisted. PET-CT showed abnormal pleural uptake; VATS biopsies confirmed epithelioid mesothelioma. The authors concluded that, though uncommon, cancer-related effusions can come and go. They advised keeping at-risk patients whose effusion has no clear explanation under surveillance, with a low threshold for further tests, even if it first settled.

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 (two cases)
• Who was studied: Two men seen at a pleural service in Perth, Australia: a 63-year-old man (Case 1) and a 78-year-old man (Case 2)
• Exposure: Case 1 worked as a carpenter with asbestos exposure and lived for three childhood years in an asbestos mining town where his father worked; his father died of mesothelioma. Case 2 installed refrigerators and air-conditioning units, which involved drilling through asbestos walls and roofs. No fiber type was named.
• Main results:
  • Case 1: the left-sided pleural effusion largely resolved without intervention within 2 weeks. Over the following 4 months it recurred and resolved spontaneously on two further occasions.
  • Case 1: VATS found abnormal parietal pleura among pleural plaques, and pleural biopsy revealed malignant epithelioid mesothelioma. No pleurodesis was performed, and the effusion had not recurred after 14 months of follow-up after VATS.
  • Case 2: the effusion significantly reduced in size without treatment within 2 days, with a small residual basal effusion remaining. The fluid was an exudate, and cytology showed reactive mesothelial cells but no evidence of malignancy.
  • Case 2: a repeat CT 2 months later showed the effusion had recurred. An ultrasound-guided pleural biopsy then showed benign fibrinous pleuritis.
  • Case 2: the effusion persisted on CT a further 6 months later, and PET-CT showed FDG-avidity in the left pleura. VATS biopsies confirmed epithelioid mesothelioma, and the effusion had not recurred at follow-up 3 months after VATS.
• The authors' conclusion: The authors concluded that, though uncommon, malignant pleural effusions can present as remitting-relapsing effusions. Patients at risk of malignant pleural effusion with no definitive explanation for their effusion should at least be kept under surveillance, with a low threshold for further investigation even if the initial effusion settled on its own.

Topics

Medical terms in this study, explained in our Lexicon: Pleural Mesothelioma, Pleural Effusion, Epithelioid, Mesothelioma.

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