Primary malignant pericardial mesothelioma with difficult antemortem diagnosis: A case report

Our plain-English summary of Primary malignant pericardial mesothelioma with difficult antemortem diagnosis: A case report, by N. Oka, Y. Orita, C. Oshita, et al (World Journal of Clinical Cases, 2022).

The study

• Authors: N. Oka, Y. Orita, C. Oshita, H. Nakayama, H. Teragawa
• Journal: World Journal of Clinical Cases
• Published: 2022;10(33):12380-12387
• Type of article: Case report
• Cited by: 5 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Background: Primary malignant pericardial mesothelioma (PMPM) is an extremely rare malignant tumor, and it is difficult to diagnose definitively before death. We present a case in which PMPM was diagnosed at autopsy. We consider this case to be highly suggestive and report it here.

Case Summary: A 78-year-old male presented with transient loss of consciousness and falls. The transient loss of consciousness was considered to result from complications of diastolic dysfunction due to pericardial disease, fever with dehydration, and paroxysmal atrial fibrillation. Ultrasound cardiography (UCG) and computed tomography showed cardiac enlargement and high-density pericardial effusion. We considered pericardial disease to be the main pathogenesis of this case. Cardiac magnetic resonance imaging and gadolinium contrast-enhanced T1-weighted images showed thick staining inside and outside the pericardium. Pericardial biopsy was considered to establish a definitive diagnosis, but the patient and his family refused further treatment and examinations, and the patient was followed conservatively. We noticed a thickening of the pericardium and massive changes in the pericardium on UCG over time. We performed an autopsy 60 h after the patient died of pneumonia. Giemsa staining of the autopsy tissue showed an epithelial-like arrangement in the pericardial tumor, and immunostaining showed positive and negative factors for the diagnosis of PMPM. Based on these findings, the final diagnosis of PMPM was made.

Conclusion: PMPM has a poor prognosis, and early diagnosis and treatment are important. The temporal echocardiographic findings may provide a clue for the diagnosis of PMPM.

©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.

In plain English

This case report described one 78-year-old man in Japan who was admitted to hospital in September 2019 after briefly losing consciousness and falling. He had smoked for 58 years, and his history of asbestos exposure was unknown. Scans showed an enlarged heart, fluid in the sac around the heart (the pericardium) and pericardial thickening, without a clear tumor. A heart ultrasound on day 23 showed a mass-like area at the tip of the heart that had not been seen on admission. A biopsy was recommended, but the patient and his family declined further tests and treatment. He died of pneumonia on day 77. An autopsy 60 hours after death found a large tumor surrounding the pericardium and growing into the heart muscle. Tissue staining led to a final diagnosis of primary malignant pericardial mesothelioma, epithelial type. The authors concluded that fluid, a mass and thickening seen on repeated heart ultrasounds may suggest this cancer. They noted that the delay before the autopsy may have affected the staining results.

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, diagnosed at autopsy)
• Who was studied: One 78-year-old man admitted to the emergency department of JR Hiroshima Hospital, Japan, in September 2019 with transient loss of consciousness and falls; he had paroxysmal atrial fibrillation, diabetes mellitus and chronic kidney disease
• Exposure: Asbestos exposure history unknown; no fiber type or occupation reported. The patient had smoked 20 cigarettes daily for 58 years.
• Main results:
  • On admission, CT showed cardiac enlargement, high-density pericardial effusion and bilateral pleural effusion
  • Cardiac MRI with gadolinium showed thick staining inside and outside the pericardium; the thickening was diffuse with no clear tumor shadow
  • Heart ultrasound on day 23 showed mass-like echogenicity at the apex that had not been present on admission
  • The patient and family refused the recommended biopsies and further treatment
  • The patient died on day 77 after admission, after developing pneumonia
  • Autopsy 60 hours after death showed a large tumor surrounding the pericardium and infiltrating the heart muscle
  • Immunostaining was positive for calretinin and podoplanin/D2-40 and negative for CEA, TTF-1, napsin A and claudin 4; WT-1 was negative
  • The tumor was classified as epithelial type
  • The case met three of the four Andersen and Hansen diagnostic criteria, not the second. The authors judged the mesothelioma found in the lungs to be metastasis from the pericardial tumor.
• The authors' conclusion: The authors concluded that the combination of pericardial effusion, mass and thickening on successive heart ultrasounds may suggest primary malignant pericardial mesothelioma. In their view, it should be considered as a possible diagnosis in pericardial disease irrespective of the absence of asbestos exposure.
• Limitations the authors state:
  • The 60-hour delay before autopsy may have affected the immunostaining results
  • FDG PET was not performed
  • Additional MRI sequences that might have helped were not performed
  • The gastrointestinal examination was not sufficient on its own and may have added burden to the patient
  • No pericardial biopsy was done; the authors felt they could have explained the procedure more

Topics

Medical terms in this study, explained in our Lexicon: Pericardial Mesothelioma, Autopsy, Pericardial, Ultrasound, Pericardial Effusion, Pericardium, Biopsy, Prognosis.

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• Case Report: Early diagnosis and bevacizumab-based chemotherapy for primary pericardial mesothelioma: a case with occupational asbestos exposure history — D. Wang, Y.H. Wang, et al. (2023)
• Timely diagnosis of primary pericardial mesothelioma — H.C. Chen, S. Chang, et al. (2020)
• Antemortem diagnosis in two cases of malignant peritoneal mesothelioma — B. Eslami, C.L. Lutcher (1974)
• Antemortem diagnosis of asbestosis by screening chest radiograph correlated with postmortem histologic features of asbestosis: a study of 273 cases — K.N. Mizell, C.G. Morris, et al. (2009)
• Difficult to Identify: Malignant Primary Peritoneal Mesothelioma — B.S. Zha, M. Flanagan, et al. (2015)

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