Primary Pericardial Mesothelioma: A Rare but Serious Consideration

Our plain-English summary of Primary Pericardial Mesothelioma: A Rare but Serious Consideration, by S. Seal, H. Simon (Curēus, 2021).

The study

• Authors: S. Seal, H. Simon
• Journal: Curēus
• Published: 2021;13(11):e19966
• Type of article: Case report
• Cited by: 9 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Primary pericardial mesothelioma (PPM) is an extremely rare malignancy with a very poor prognosis. It poses a diagnostic challenge given its often late and non-specific presentation. This report describes a 74-year-old man who presented with central pleuritic chest pain and mild breathlessness. The patient was febrile and mildly tachycardic with crepitations in the right lung base. Blood tests revealed raised inflammatory markers and chest X-ray showed no acute pathology. Following admission, CT pulmonary angiogram showed a large left-sided mediastinal mass (approximately 110 x 70 x 85 mm) centered on the pericardium. Further post venous phase CT imaging identified possible myocardial invasion alongside suspicious liver nodules. Later, outpatient fluorodeoxyglucose (FDG) positron emission tomography (PET) imaging highlighted further FDG avid pleural and liver lesions. CT-guided biopsy of the pericardial lesion was undertaken, with histology and immunohistochemistry indicating epitheliod-type mesothelioma. A significant malignant pericardial effusion was also identified, which ultimately required pericardial window formation. Immunotherapy was commenced utilizing dual nivolumab and ipilimumab, a novel regime for the treatment of mesothelioma. Palliative radiotherapy to the pericardial lesion will also be performed. Here, we demonstrate the diagnostic challenge of this vanishingly rare condition, which is usually diagnosed upon the development of associated complications. Early recognition gives the best chance of improved mortality, however, diagnosis requires a high index of clinical suspicion alongside prompt investigation, primarily involving cross-sectional imaging.

Copyright © 2021, Seal et al.

In plain English

This case report described one patient, a 74-year-old retired boilermaker with a history of asbestos exposure and known pleural plaques. He went to an emergency department with central chest pain that worsened on breathing, and mild breathlessness. Pneumonia was diagnosed at first. A CT scan done to rule out a blood clot in the lungs instead found a mass of about 110 x 70 x 85 mm centered on the pericardium (the sac around the heart). The scan also showed possible invasion of the heart muscle and fluid around the heart. A later PET scan showed further suspicious areas in the pleura, liver, adrenal glands and lymph nodes. A needle biopsy of a small nodule just under the lining of the left lung showed epithelioid-type mesothelioma, and the doctors judged the primary tumor to be pericardial mesothelioma. He received the immunotherapy drugs nivolumab and ipilimumab with palliative intent, radiotherapy was being planned, and the fluid around the heart was drained. The authors concluded that this disease is commonly diagnosed through its complications. The report did not give the patient's outcome.

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)
• Who was studied: One 74-year-old man, a retired boilermaker, seen in an emergency department. The authors are from General Medicine, Central Coast Local Health District, Gosford, Australia. No dates of care are given.
• Exposure: A history of asbestos exposure, with known asbestos-related plaques. The fiber type, products and dose are not described. His occupation was retired boilermaker.
• Main results:
  • Pneumonia was diagnosed at first in the emergency department.
  • A CT pulmonary angiogram found a large left-sided mediastinal mass centered on the pericardium, measuring approximately 110 x 70 x 85 mm.
  • Imaging suggested possible invasion of the heart muscle (myocardium).
  • A PET scan showed an enlarging, intensely FDG avid mass at the left lower mediastinal border, with a maximum standard uptake value of 21.7, and a large pericardial effusion up to 4 cm deep. Smaller FDG avid pleural masses, liver masses, adrenal thickening and suspicious lymph nodes were also noted.
  • There was no evidence of local recurrence of his previously treated colorectal cancer.
  • A CT-guided biopsy of a subpleural lingular nodule showed epithelioid-type mesothelioma. The primary lesion was thought to be pericardial mesothelioma.
  • He was treated with nivolumab and ipilimumab, with radiotherapy planned. Both treatments had palliative intent.
  • The enlarging malignant pericardial effusion was drained by pericardiocentesis and a pericardial window without major complication.
• The authors' conclusion: The authors concluded that diagnosis of primary pericardial mesothelioma commonly comes about through its complications. In this case that was pleuritic chest pain likely caused by a mediastinal mass.
• Limitations the authors state:
  • The authors stated that because there are few cases, especially ones diagnosed before death, it is difficult to study this disease in clinically useful ways.
  • The authors noted that the trial supporting nivolumab plus ipilimumab excluded patients with primary pericardial presentations and those with a prior cancer without a three-year disease-free remission. Its direct applicability to this case is therefore difficult.

Topics

Medical terms in this study, explained in our Lexicon: Pericardial Mesothelioma, Prognosis, Pleuritic Chest Pain, Chest X-Ray, Pathology, Pericardium, Biopsy, Pericardial.

Related studies

• Primary pericardial mesothelioma: a rare entity — M. Godar, J. Liu, et al. (2013)
• Primary malignant pericardial mesothelioma - a rare cause of pericardial effusion and consecutive constrictive pericarditis: a case report — T. Butz, L. Faber, et al. (2009)
• A case report of an extremely rare and aggressive tumor: primary malignant pericardial mesothelioma — X. Feng, L. Zhao, et al. (2012)
• A rare case of primary malignant pericardial mesothelioma — R. Ramachandran, P. Radhan, et al. (2014)
• Primary pericardial mesothelioma and asbestos exposure: a rare fatal disease — D.M.M. Freitas, R.L. Ramos, et al. (2017)
• F-18 FDG PET/CT images of a rare primer cardiac tumour: Primary Pericardial Mesothelioma — İ. Ak Sivrikoz, H. Önner, et al. (2016)

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