Cervical endometriosis associated with malignant pleural mesothelioma mimicking cervical cancer--Occam's razor or the "third man"

Our plain-English summary of Cervical endometriosis associated with malignant pleural mesothelioma mimicking cervical cancer--Occam's razor or the "third man", by J.B. Engel, S. Heuer, S. Segerer, et al (Fertility and Sterility, 2011).

The study

• Authors: J.B. Engel, S. Heuer, S. Segerer, S. Rauthe, J. Dietl, A. Hönig
• Journal: Fertility and Sterility
• Published: 2011;95(5):1787.e5-7
• Type of article: Case report
• Cited by: 2 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Objective: To illustrate pitfalls in the diagnosis of endometriosis and cervical cancer.

Design: Case report.

Setting: University hospital, department of obstetrics and gynecology.

Patient(s): A 45-year-old woman with menorrhagia, pelvic mass, right-sided hydronephrosis, and unexplained weight loss.

Intervention(s): Cervical biopsies were suggestive of cervical endometriosis. Laparoscopy confirmed endometriosis. Associated pleural effusion, without cytologic signs of malignancy, was interpreted as caused by thoracic endometriosis. The patient had a transabdominal hysterectomy and unilateral salpingo-oophorectomy. Histopathologic examination confirmed endometriosis and revealed a residual tubo-ovarian abscess. After surgery, the patient developed spontaneous seropneumothorax. Pleural biopsies revealed a well-differentiated epithelial malignant pleural mesothelioma. The patient underwent hypofractionated radiation of drain sites. She is now observed in our outpatient clinic.

Main Outcome Measure(s): Steps to the correct diagnosis.

Result(s): The patient had an association of cervical and pelvic endometriosis, residual tubo-ovarian abscess, and malignant pleural mesothelioma.

Conclusion(s): Usually, the simplest diagnosis explaining a complex of symptoms and clinical and diagnostic findings is the one most likely to be correct. This is an application of Occam's razor to medicine. Our case illustrates that occasionally the simplest and therefore most probable diagnosis can be wrong, and on these occasions one should consider a "third man."

Copyright © 2011 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.

In plain English

This case report from a university hospital in Würzburg, Germany, described a 45-year-old premenopausal woman with six weeks of heavy menstrual bleeding and weight loss of unclear origin. A pelvic mass suggested cervical cancer, but biopsies showed endometriosis instead. A right-sided pleural effusion showed no malignant cells and was first attributed to endometriosis in the chest. After abdominal hysterectomy, pathology showed adenomyosis, endometriosis and a right tubo-ovarian abscess, with no malignancy. The patient then developed a spontaneous seropneumothorax, and pleural biopsies revealed a well-differentiated epithelial malignant pleural mesothelioma. Several independent pathologists agreed on this diagnosis. The patient had no known asbestos exposure. The authors called this nonconclusive because the patient lived on a farmstead with unknown construction material. The patient received radiation to the drain sites (21 Gy) and refused chemotherapy. A CT scan 8 months after first presentation showed progressive pleural thickening. The authors concluded that the simplest diagnosis is usually correct, but that occasionally a 'third man' should be considered.

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
• Who was studied: One 45-year-old premenopausal woman treated at the Department of Obstetrics and Gynecology, Medical University of Würzburg, Germany. She was referred with menorrhagia lasting 6 weeks and weight loss of unclear origin.
• Exposure: The patient denied occupational exposure to hazardous substances. Later inquiry found no known asbestos exposure. The authors considered this nonconclusive because the patient lives on a farmstead with unknown construction material. No fiber type is named.
• Main results:
  • Cervical biopsy did not show cervical cancer but did show ulcerative endometriosis.
  • Laboratory tests showed slightly elevated CA-125 (141.9 U/mL; reference 0 to 35 U/mL).
  • Cytology of 1,000 mL of hemorrhagic pleural effusion showed mesothelial hyperplasia and hyperchromasia but no malignant cells.
  • Pathology after hysterectomy with right salpingo-oophorectomy and left salpingectomy showed adenomyosis, endometriosis of the left fallopian tube and an extensive right tubo-ovarian abscess, with no evidence of malignancy.
  • After surgery the patient developed a left spontaneous seropneumothorax. Pleural biopsies revealed a well-differentiated epithelial malignant pleural mesothelioma.
  • Immunohistochemical staining (calretinin, D2-40, CK5/6, CK7, EMA) showed invasive tumor growth. Several independent pathologists agreed on epithelial malignant pleural mesothelioma in a panel discussion.
  • The patient had hypofractionated radiation of drain sites to a cumulative dose of 21 Gy and refused systemic chemotherapy with cisplatin and pemetrexed (spelled 'permetrexed' in the article).
  • Follow-up CT of the thorax 8 months after initial presentation showed progressive pleural thickening, a constant left-sided pneumothorax and minimal pleural effusion.
• The authors' conclusion: The authors concluded that the simplest explanation is usually correct (Occam's razor). In rare cases, however, simplification leads to misdiagnosis, and considering the improbable or a 'third man', as in this case, helps find the correct diagnosis.
• Limitations the authors state:
  • The authors note that the absence of known asbestos exposure is nonconclusive, because the patient lives on a farmstead with unknown construction material.

Topics

The National Library of Medicine indexes this study under subjects our site covers: Mesothelioma.

Medical terms in this study, explained in our Lexicon: Pleural Mesothelioma, Pleural Effusion, Well-Differentiated.

Related studies

• Peritoneal mesothelial hyperplasia associated with gynaecological disease: a potential diagnostic pitfall that is commonly associated with endometriosis — R. Oparka, W.G. McCluggage, et al. (2011)
• An incidental diagnosis of well-differentiated papillary mesothelioma in a woman operated on for recurrent endometriosis — R. Mangal, O. Taskin, et al. (1995)
• Occam's Razor versus Hickam's Dictum — T.A. Newman, J.E. Takasugi, et al. (2017)
• Mesothelin as a target for cervical cancer therapy — K. Jöhrens, L. Lazzerini, et al. (2019)
• Multicystic mesothelioma with endometriosis — G.M. Groisman, H. Kerner (1992)
• Multicystic mesothelioma caused by endometriosis: 2 case reports and review of the literature — Y. Kurisu, M. Tsuji, et al. (2011)

Browse return to medical research.