Constrictive pericarditis after left extrapleural pneumonectomy and radiotherapy for malignant mesothelioma

Our plain-English summary of Constrictive pericarditis after left extrapleural pneumonectomy and radiotherapy for malignant mesothelioma, by E.J. Hickey, A.A. Khan, J.B. Chambers, et al (Journal of Thoracic Oncology, 2007).

The study

• Authors: E.J. Hickey, A.A. Khan, J.B. Chambers, L. Lang-Lazdunski
• Journal: Journal of Thoracic Oncology
• Published: 2007;2(7):673-5
• Type of article: Case report
• Cited by: 3 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

We report the devastating complication of constrictive pericarditis after multimodality therapy including left extrapleural pneumonectomy for malignant pleural mesothelioma. The patient presented with progressive dyspnea, ascites, and peripheral edema 6 months after receiving adjuvant radiotherapy. A diagnosis of constrictive pericarditis was made late in the clinical course after exhaustive investigation to exclude primary disease recurrence. Pericardial decortication was subsequently undertaken 12 months after the initial surgery, but the patient died of multi-organ failure. Our experience, combined with a review of the available literature, leads us to advise a low level of suspicion and early operation to relieve cardiac constriction. Furthermore, these complications emphasize the importance of trials such as the Mesothelioma and Radical Surgery (MARS) study.

In plain English

This was a case report about one patient. A 60-year-old male non-smoker had malignant pleural mesothelioma of the epithelioid subtype on the left side. No asbestos exposure was described. The patient was treated with talc pleurodesis, port-site radiotherapy (21 Gy in 3 fractions) and three cycles of gemcitabine and cisplatin chemotherapy. Surgeons performed a left extrapleural pneumonectomy, removing the left side of the pericardium and the left half of the diaphragm, both rebuilt with mesh. Radiotherapy of 54 Gy in 30 fractions to the left chest and mediastinum followed. Six months later the patient returned with worsening breathlessness and later developed signs of right heart failure. Tests found no sign that the cancer had come back. Right heart catheterization confirmed constrictive pericarditis. At surgery, thick fibrous tissue covering the right ventricle was removed. The patient then developed breathing failure, cardiac arrest and multi-organ failure, and died. Autopsy found no evidence of recurrent mesothelioma. The authors attributed the constriction more probably to the high-dose radiotherapy. They concluded that patients with exertional symptoms after such treatment should be examined for constrictive cardiac physiology.

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 of a single patient
• Who was studied: one 60-year-old male non-smoker with left malignant pleural mesothelioma, epithelioid subtype, disease stage T3N0M0; place and date of treatment not stated
• Exposure: No asbestos exposure is described. The case concerns treatment: talc pleurodesis, port-site radiotherapy (21 Gy in 3 fractions), neoadjuvant chemotherapy (three cycles, gemcitabine and cisplatin), and left extrapleural pneumonectomy. The surgery removed the left side of the pericardium and the left hemi-diaphragm, both reconstructed with mesh. It was followed by adjuvant radiotherapy to the left hemithorax and mediastinum of 54 Gy in 30 fractions.
• Main results:
  • When the patient re-presented six months after radiotherapy with breathlessness and a right pleural effusion, fluid from the chest showed no malignant cells
  • Constrictive pericarditis was confirmed on right heart catheterization
  • At surgery, the whole free wall of the right ventricle was encased in thickened fibrous tissue, which was removed
  • After surgery the patient developed respiratory insufficiency and cardiac arrest on day 2; multi-organ failure followed and the patient died 4 days later
  • Autopsy and examination of surgical specimens showed pericardial fibrosis with no evidence of recurrent mesothelioma
• The authors' conclusion: The authors attributed the constriction possibly to the left pericardial resection with mesh replacement and povidone iodine use, but more probably to the high-dose radiotherapy given after surgery. They concluded that any patient re-presenting with exertional symptoms after radical multimodality therapy should be examined for constrictive cardiac physiology. They also stated that such complications show the importance of trials such as the MARS trial.

Topics

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

Medical terms in this study, explained in our Lexicon: Extrapleural Pneumonectomy (EPP), Malignant Mesothelioma, Multimodal Therapy, Pleural Mesothelioma, Dyspnea, Ascites, Pericardial, Mesothelioma.

Related studies

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• Pericardiectomy for treatment of neoplastic constrictive pericarditis — F. Buyukbayrak, E. Aksoy, et al. (2014)
• Chronic constrictive pericarditis associated with asbestosis — L. Fischbein, M. Namade, et al. (1988)
• Asbestos induced pericardial effusion and constrictive pericarditis — D. Davies, M.I. Andrews, et al. (1991)
• 18F-FDG PET/CT Revealing Constrictive Pericarditis as the Only Manifestation of Malignant Mesothelioma — J.P. Edel, H. Balink (2019)
• A case of pleural mesothelioma with effusive-constrictive pericarditis — N.A. Weir, B. Gerstenhaber (2001)

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