An Autopsied Case of Malignant Sarcomatoid Pleural Mesothelioma in Which Chest Pain Developed Several Months Earlier without Abnormality on Imaging

Our plain-English summary of An Autopsied Case of Malignant Sarcomatoid Pleural Mesothelioma in Which Chest Pain Developed Several Months Earlier without Abnormality on Imaging, by D. Yaguchi, M. Ichikawa, N. Inoue, et al (Case Reports in Oncology, 2015).

The study

• Authors: D. Yaguchi, M. Ichikawa, N. Inoue, D. Kobayashi, A. Matsuura, M. Shizu, N. Imai, K. Watanabe
• Journal: Case Reports in Oncology
• Published: 2015;8(3):439-46
• Type of article: Case report
• Read it: PubMed · Publisher · Free full text

Abstract

The patient experienced chest pain for about 7 months, but a diagnosis could not be made until after death. He was diagnosed with malignant sarcomatoid pleural mesothelioma on autopsy. In this case report, difficult aspects of the diagnosis are discussed. The 70-year-old Japanese man was a driver who transported ceramic-related products. Right chest pain developed in July 2013, but no abnormality was detected on a chest computed tomography (CT) performed in September 2013, and the pain was managed as right intercostal neuralgia. A chest CT performed in late October 2013 revealed a right pleural effusion, and the patient was referred to our hospital in early November 2013. Thoracentesis was performed, but the cytology was negative, and no diagnosis could be made. Close examination was postponed because the patient developed a subarachnoid hemorrhage. He underwent (18)F-fluorodeoxyglucose positron emission tomography ((18)F-FDG PET) after discharge from the neurosurgery department, and extensive right pleural thickening and (18)F-FDG accumulation in this region were observed. Based on these findings, malignant pleural mesothelioma was suspected, and a thoracoscopy was performed under local anesthesia in early December 2013, but no definite diagnosis could be made. The patient selected best supportive care and died about 7 months after the initial development of right chest pain. The disease was definitively diagnosed as malignant sarcomatoid pleural mesothelioma by a pathological autopsy. When chronic chest pain of unknown cause is observed and past exposure to asbestos is suspected, actions to prevent delay in diagnosis should be taken, including testing for suspicion of malignant pleural mesothelioma.

In plain English

This case report described a 70-year-old Japanese man, a driver who transported ceramic-related products; the authors described his asbestos exposure as unclear. Right chest pain began in July 2013. A chest CT about two months later showed no abnormality, and the pain was managed as nerve pain between the ribs. A CT in late October 2013 showed fluid and thickening of the lining around the right lung (the pleura). A brain bleed (subarachnoid hemorrhage) delayed testing. In early December 2013, a PET/CT scan showed uptake in the thickened pleura. A thoracoscopy found pleural plaques and small protrusions, but the biopsy gave no definite diagnosis. He chose supportive care and died in February 2014, 7 months after the pain began. An autopsy, which excluded the brain, diagnosed malignant sarcomatoid pleural mesothelioma that had spread to the heart surface, liver, skin and a lymph node. The authors attributed the disease to asbestos because pleural plaques were seen. They did not look for asbestos in the lung. They concluded that mesothelioma should be considered in patients with chronic chest pain and suspected asbestos exposure even when CT shows no abnormality.

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 autopsied patient)
• Who was studied: one 70-year-old Japanese man, a non-smoking driver, treated at Gifu Prefectural Tajimi Hospital, Japan, 2013 to 2014
• Exposure: Job as a driver transporting ceramic-related products; asbestos exposure described as unclear; lung tissue was not examined for asbestos
• Main results:
  • A chest CT in September 2013, about 2 months after chest pain began, showed no pleural thickening or effusion. A CT in late October 2013 showed a right pleural effusion with right pleural thickening.
  • The chest pain had been managed as right intercostal neuralgia (nerve pain between the ribs)
  • The pleural fluid showed no atypical cells
  • PET/CT in early December 2013 showed uptake in the thickened right pleura, with a maximum standardized uptake value of 7.7
  • Thoracoscopy found pleural plaques on the parietal pleura and many small white protrusions
  • The pleural biopsy could not distinguish lung cancer from mesothelioma, so no definite diagnosis was made before death
  • The patient died in February 2014, 7 months after chest pain began and 3 months after referral
  • The autopsy excluded the brain. It showed metastases in the epicardium (heart surface), liver, skin and a hilar lymph node.
  • Malignant sarcomatoid pleural mesothelioma was definitively diagnosed at autopsy
  • The authors attributed the mesothelioma to asbestos exposure because of pleural plaques; they did not look for asbestos in the lung
• The authors' conclusion: The authors concluded that when asbestos exposure is suspected in a patient with chronic chest pain, malignant pleural mesothelioma should be considered even if CT shows no abnormality
• Limitations the authors state:
  • The brain was not autopsied, so brain metastasis as a cause of the subarachnoid hemorrhage could not be checked

Topics

Medical terms in this study, explained in our Lexicon: Sarcomatoid, Pleural Mesothelioma, Autopsy, Pleural Effusion, Thoracentesis, Cytology, Pleural Thickening, Thoracoscopy.

Related studies

• Sarcomatoid mesothelioma diagnosed in a patient with mesothelioma in situ: a case report on morphologic differences after 9-month interval with details analysis of cytology in early-stage mesothelioma — M. Yoshida, N. Jimbo, et al. (2023)
• Imaging of pleural masses: which to choose? — A.S. Bruns, J.G. Mastronarde (2008)
• Chest pain in asbestos-exposed individuals with benign pleural and parenchymal disease — S. Mukherjee, N. de Klerk, et al. (2000)
• Chest pain and ST elevation: not always ST-segment-elevation myocardial infarction — S.A. Pyxaras, G. Lardieri, et al. (2010)
• Chest pain in asbestos and silica-exposed workers — E.K. Park, P.S. Thomas, et al. (2011)
• A retrospective study of chest pain in benign asbestos pleural disease — R.K. Allen, T. Cramond, et al. (2011)

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