Positron emission tomography/computed tomography in risk-factor-negative young female with malignant pleural mesothelioma: A case report and review of literature

Our plain-English summary of Positron emission tomography/computed tomography in risk-factor-negative young female with malignant pleural mesothelioma: A case report and review of literature, by A. Aisikaer, M.M. Sun, J. Shen (World Journal of Clinical Cases, 2025).

The study

• Authors: A. Aisikaer, M.M. Sun, J. Shen
• Journal: World Journal of Clinical Cases
• Published: 2025;13(32):110897
• Type of article: Case report
• Read it: PubMed · Publisher · Free full text

Abstract

Background: Malignant pleural mesothelioma (MPM), a rare aggressive malignancy, is primarily caused by asbestos exposure. MPM typically affects older adults (median age, 76 years), is uncommon in those under age 50 years and shows male predominance. Based on the American Society of Clinical Oncology guidelines, F-18 fluorodeoxyglucose positron emission tomography/computed tomography (F-18 FDG PET/CT) is essential for initial MPM staging. Integrating quantitative FDG metabolic data with computed tomography (CT) anatomy optimizes biopsy accuracy and staging.

Case Summary: A 21-year-old female college student presented with fever (peak 38.4 °C), cough, and white mucoid sputum after cold exposure. Initial evaluation revealed elevated C-reactive protein [C-reactive protein (CRP); 65.52 mg/L] and Mycoplasma pneumoniae IgM. Despite resolution of fever following a 14-day moxifloxacin regimen, persistent cough prompted chest CT, which demonstrated left pleural mass-like thickenings. Levofloxacin therapy for 2 weeks failed to alleviate symptoms, accompanied by 2.5-kg weight loss over 1 month. Re-evaluation showed rising CRP (88.87 mg/L) with stable CT lesions, and negative T-cell spot test for tuberculosis and tumor markers. Contrast-enhanced CT revealed heterogeneously enhancing masses, while PET/CT detected two broad-based pleural lesions with intense FDG avidity. CT-guided biopsy confirmed epithelioid MPM. Thoracoscopy exposed diffuse fragile, hemorrhagic nodules implanting on diaphragmatic and parietal pleura, confirming metastatic MPM with partial resection performed. This presentation challenges conventional imaging paradigms of MPM, underscoring its diagnostic complexity.

Conclusion: MPM should still be considered an important differential diagnosis in young patients presenting with solitary pleural masses and no history of typical asbestos exposure. F-18 FDG PET/CT, while serving as an essential component of initial staging for MPM, has some inherent limitations.

©The Author(s) 2025. Published by Baishideng Publishing Group Inc. All rights reserved.

In plain English

This case report, with a discussion of published literature, came from the Department of Nuclear Medicine at Tianjin First Central Hospital, China. It described a 21-year-old female college student without documented asbestos exposure. She had fever, cough and sputum. Her cough persisted after antibiotics, and chest CT showed two masses on the left pleura. A tuberculosis test was negative and tumor markers were normal. PET/CT showed intense FDG uptake in both masses (SUVmax 14.0 and 13.7) and no other FDG-avid lesions. A CT-guided biopsy confirmed epithelioid malignant pleural mesothelioma. At surgery, scattered nodules were found over the diaphragmatic and parietal pleura, which PET/CT had not shown, and a partial pleurectomy was performed. She then received pemetrexed and carboplatin, with pembrolizumab added from cycle 2. CT after cycle 3 showed stable disease, and grade 3 anemia developed. The authors concluded that mesothelioma should still be considered in young patients with pleural masses and no history of typical asbestos exposure, and that PET/CT has inherent limitations, including missing very small lesions.

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 of one patient, with a narrative discussion of earlier published literature
• Who was studied: One 21-year-old female college student, managed at Tianjin First Central Hospital, Tianjin, China. Dates of care are not given.
• Exposure: No documented asbestos exposure. No fiber type, product or job is described for the patient.
• Main results:
  • Initial chest CT showed two masses attached to the left pleura, measuring 4.6 cm by 3.6 cm by 6.5 cm and 1.8 cm by 4.7 cm by 6.1 cm.
  • In this patient, the tuberculosis blood test (T-SPOT.TB) was negative and the tumor markers tested were within normal ranges.
  • PET/CT showed intensely elevated FDG uptake in both lesions (SUVmax 14.0 and 13.7) and no other FDG-avid lesions elsewhere in the body.
  • A CT-guided pleural biopsy confirmed epithelioid malignant pleural mesothelioma.
  • During thoracoscopic surgery, scattered nodules were found spread over the diaphragmatic and parietal pleura. PET/CT had not shown these spread lesions. A partial pleurectomy was performed.
  • The authors stated that PET/CT failed to show the spread of small tumor deposits across the pleura.
  • The patient received pemetrexed plus carboplatin, with pembrolizumab added from cycle 2. CT after cycle 3 showed stable disease. Grade 3 anemia developed (hemoglobin fell from 118 to 77 g/L) and required erythropoietin support.
  • The FDG uptake in this epithelioid tumor was higher than typical sarcomatoid cases described in other studies. The authors suggested this was potentially attributable to concurrent Mycoplasma pneumoniae inflammation.
• The authors' conclusion: The authors concluded that malignant pleural mesothelioma should still be considered in young patients with solitary pleural masses and no history of typical asbestos exposure. They also concluded that F-18 FDG PET/CT, though essential for initial staging, has some inherent limitations.

Topics

Medical terms in this study, explained in our Lexicon: Pleural Mesothelioma, Asbestos Exposure, Staging, Biopsy, Sputum, Tumor Marker, Epithelioid, Thoracoscopy.

Related studies

• Clinical value of fluorodeoxyglucose-positron emission tomography/computed tomography in differentiation of malignant mesothelioma from asbestos-related benign pleural disease: an observational pilot study — H. Yildirim, M. Metintas, et al. (2009)
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• Clinical implications of 18F-fluorodeoxyglucose positron emission tomography/computed tomography at delayed phase for diagnosis and prognosis of malignant pleural mesothelioma — Y. Abe, K. Tamura, et al. (2012)
• Clinical utility of 18-fluorodeoxyglucose positron emission tomography/computed tomography in malignant pleural mesothelioma — T. Terada, C. Tabata, et al. (2012)
• Integrated positron emission tomography-computed tomography does not accurately stage intrathoracic disease of patients undergoing trimodality therapy for malignant pleural mesothelioma — J. Pilling, J.A. Dartnell, et al. (2010)
• Use of computed tomography and positron emission tomography/computed tomography for staging of local extent in patients with malignant pleural mesothelioma — T. Frauenfelder, P. Kestenholz, et al. (2015)

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