A Case of Pulmonary Embolism with Sarcomatoid Malignant Pleural Mesothelioma with Long-Term Pleural Effusion

Our plain-English summary of A Case of Pulmonary Embolism with Sarcomatoid Malignant Pleural Mesothelioma with Long-Term Pleural Effusion, by R. Gu, L. Jiang, T. Duan, et al (OncoTargets and Therapy, 2021).

The study

• Authors: R. Gu, L. Jiang, T. Duan, C. Chen, S. Wu, D. Mu
• Journal: OncoTargets and Therapy
• Published: 2021;14:4231-4237
• Type of article: Case report
• Read it: PubMed · Publisher · Free full text

Abstract

Background: Malignant pleural mesothelioma (MPM) is a highly aggressive tumor that originates from pleural mesothelial cells. In recent years, with the development of asbestos-related industries and the increase in air pollution, its incidence has been increased. The incidence of pulmonary embolism combined with sarcomatoid MPM is very low and the prognosis is extremely poor. We here report a case of a patient with long term of pleural effusion and finally diagnosed as pulmonary embolism with sarcomatoid MPM.

Case: A 75-year-old male with a 30-year history of asbestos exposure was admitted to our hospital due to chest pain and difficulty in breathing after exercise. Radiologic examination revealed pleural effusion, computed tomography pulmonary angiography (CTPA) suggests pulmonary embolism, and we consider pleural effusion caused by pulmonary embolism. After anticoagulant therapy for pulmonary embolism and pleural puncture to reduce pleural effusion, the patient's symptoms improved. However, after that, the patient was still admitted to the hospital several times because of recurrent chest pain and dyspnea symptoms, and radiologic examination always showed unexplained pleural effusion. Finally, pathological and immunohistochemical examinations of the pleural biopsy specimens were performed, and the diagnosis was confirmed as sarcomatoid MPM.

Conclusion: In summary, sarcomatoid MPM with pulmonary embolism is relatively rare, and the prognosis is poor. Clinicians need to be alert to its occurrence. When the first diagnosis is confirmed and the effect of targeted treatment is still not good, the possibility of other diseases should be considered. In clinical practice, pleural biopsy guided by PET-CT is a good choice for patients with sarcomatoid MPM who cannot tolerate open pleural biopsies or thoracoscopy. And patients should undergo pleural morphology and immunohistochemistry as soon as possible, which are helpful for timely diagnosis.

© 2021 Gu et al.

In plain English

This was a case report of one patient at Zhejiang Provincial People's Hospital, China. A 75-year-old man was admitted in November 2018 after two weeks of chest pain and breathlessness on exercise. Scans showed thickened, calcified lining around both lungs (the pleura) and fluid around the left lung. No tumor cells were found in the fluid sample examined. He had 30 years of close contact with asbestos. The article did not state his job or the asbestos fiber type involved. A scan found a clot in a branch of the right lung artery (pulmonary embolism). He was given blood thinners, so no open biopsy was done. He improved but was readmitted several times with returning fluid. A PET-CT scan suggested a malignant tumor. An ultrasound-guided biopsy with tissue staining led to a diagnosis of sarcomatoid pleural mesothelioma. Two days later his heart stopped. He died 2 days after leaving hospital. The authors noted the cancer was not diagnosed in time at the first visit. They concluded that fluid not clearing after its suspected cause is treated needs further investigation.

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 75-year-old man admitted to Zhejiang Provincial People's Hospital, China, on 23 November 2018, followed until his death after a hospitalization beginning 8 July 2019
• Exposure: 30 years of close contact with asbestos, learned from his occupational history. The article does not give this patient's fiber type, job or dose.
• Main results:
  • At first admission, chest CT showed diffuse thickening and calcification of the pleura on both sides, with pleural effusion and atelectasis on the left
  • The first pleural fluid sample was a bloody exudate, and no tumor cells were found in it
  • Pleural fluid sent for pathological examination many times later also showed no tumor cells
  • CT pulmonary angiography showed an embolism in a branch of the right pulmonary artery. Anticoagulants were given, and no open pleural biopsy was done because of bleeding risk.
  • After discharge he was readmitted several times, and chest CT still showed a large left pleural effusion
  • At the July 2019 admission, D-dimer and CT pulmonary angiography showed no obvious abnormality, which ruled out a recurrent embolism
  • PET-CT showed increased FDG uptake, and a malignant tumor was considered
  • In the ultrasound-guided pleural biopsy, immunohistochemistry was positive for CK(Pan), WT1 and GATA3. It was negative for the other markers tested, including calretinin, CK5/6 and D2-40.
  • The final diagnosis was sarcomatoid pleural mesothelioma
  • Two days after diagnosis he had a sudden cardiac arrest. The authors considered acute myocardial infarction or acute pulmonary embolism as possible causes.
  • After resuscitation he was discharged voluntarily and died 2 days later
• The authors' conclusion: The authors concluded that a pleural effusion that does not resolve after its suspected cause has been treated needs further work-up. They also concluded that PET-CT-guided pleural biopsy is a good choice for diagnosing sarcomatoid MPM in patients who cannot tolerate open pleural biopsy or medical thoracoscopy.
• Limitations the authors state:
  • The authors acknowledged that anticoagulation did not absolutely rule out a diagnostic thoracoscopic procedure under local anesthesia, and that the mesothelioma was not diagnosed in time at the first visit

Topics

Medical terms in this study, explained in our Lexicon: Sarcomatoid, Pleural Mesothelioma, Pleural Effusion, Mesothelial Cells, Prognosis, Asbestos Exposure, Dyspnea, Pleural Biopsy.

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