Diffuse epithelioid malignant mesothelioma of the pleura presenting as a hydropneumothorax and vertebral body invasion

Our plain-English summary of Diffuse epithelioid malignant mesothelioma of the pleura presenting as a hydropneumothorax and vertebral body invasion, by C.A. Hinkamp, S.N. Dalal, Y. Butt, et al (BMJ Case Reports, 2020).

The study

• Authors: C.A. Hinkamp, S.N. Dalal, Y. Butt, A.V. Cabo Chan
• Journal: BMJ Case Reports
• Published: 2020;13(1)
• Type of article: Case report
• Cited by: 1 article, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Malignant mesothelioma is an uncommon form of neoplastic transformation of the mesothelial cells that line the serosal surfaces of the body. It most commonly affects the pleura and is often associated with pleural effusions and pleural-based masses. The annual incidence in the United States is only 3300 cases, representing less than 0.3% of all cancers worldwide, although this is likely underestimated. We present a case of diffuse epithelioid malignant pleural mesothelioma in a patient with remote, short-term asbestos exposure complicated by recurrent left-sided hydropneumothoraces and pleural-based invasion of the T12 vertebral body, which represent two rare coexisting complications. This case illustrates the importance of maintaining a broad differential for hydropneumothorax, particularly as the risk factors may be decades removed and the degree of asbestos exposure to induce a malignant mesothelioma may be smaller than has been traditionally thought.

© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.

In plain English

This case report describes one patient. A 73-year-old Hispanic man who had never used tobacco went to an emergency department with left-sided chest pain, breathlessness, night sweats and weight loss. He had worked as a handyman, mostly in Mexico. About 20 years earlier he spent a few months as a demolition worker, frequently exposed to building materials including insulation. Two years before, he had had a left-sided pleural effusion drained. Imaging showed a large left-sided hydropneumothorax (air and fluid in the chest), a pleural-based mass invading the T12 vertebra, and many small nodules in both lungs. Tests for tuberculosis and fungal infection were negative. A pleural biopsy supported a diagnosis of diffuse malignant mesothelioma of epithelioid type. The authors later described the disease as Stage IV mesothelioma of the pleura. Four months later he had received three courses of palliative chemotherapy and one cycle of radiation to T12, and his pleural masses had shrunk by 0.5 to 1.0 cm. The authors believed his exposure was likely to amosite and crocidolite. They concluded that the asbestos exposure needed to introduce risk may be smaller than traditionally thought.

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 73-year-old Hispanic man, born in Mexico, who spent most of his adult life there before moving to the United States after retiring. He had never used tobacco.
• Exposure: A lifelong handyman (construction, roofing, plumbing). About 20 years before presentation he worked for a few months as a demolition worker, frequently exposed to building materials including insulation. No measured fiber type or dose is reported.
• Main results:
  • CT showed numerous 4 mm nodules in both lungs and destruction of the left side of the T12 vertebral body, along with a left-sided hydropneumothorax and a large 6×14×12 cm apical pleural thickening.
  • MRI showed the vertebral lesion to be a pleural-based mass invading the T12 vertebral body.
  • Tests for tuberculosis and endemic fungal infections were negative.
  • On the pleural biopsy, tumor cells were positive for calretinin, WT-1 and D2-40 and negative for TTF-1, napsin A and MOC-31. These findings supported diffuse malignant mesothelioma of epithelioid type. BAP1 expression was retained.
  • Separate staging imaging found no further distant metastases. The disease was then treated as Stage IV diffuse epithelioid malignant mesothelioma of the pleura with planned palliative chemotherapy.
  • Four months after presentation, the patient had completed three courses of chemotherapy and one cycle of palliative radiation to T12. His pleural masses had shrunk by 0.5 to 1.0 cm, and his back and chest pain had improved.
  • The authors judged that the patient's exposure was likely to both amosite and crocidolite, lasted on the order of months, and was followed by a latency of about 20 years. This is the authors' assessment, not a measured result.
  • The patient had a left-sided pleural effusion drained 2 years before. The authors suggested he may have had mesothelioma at that point.
• The authors' conclusion: The authors concluded that the case shows the importance of keeping a broad differential diagnosis for hydropneumothorax. In their view, the history pointing to mesothelioma may be decades in the past, and the asbestos exposure needed to introduce risk may be smaller than traditionally thought.

Topics

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

Medical terms in this study, explained in our Lexicon: Epithelioid, Malignant Mesothelioma, Pleura, Mesothelial Cells, Serosal Surface, Pleural Effusion, Pleural Mesothelioma, Asbestos Exposure.

Related studies

• Lepidic intrapulmonary growth of malignant mesothelioma presenting as recurrent hydropneumothorax — H. Wu, G. Tino, et al. (1996)
• Recurrent hydropneumothorax as a presenting feature of malignant mesothelioma — K. Guha, D. Jones, et al. (2008)
• Malignant pleural mesothelioma presenting with a spontaneous hydropneumothorax: a report of 2 cases — H.Z. Saleh, E. Fontaine, et al. (2012)
• Simultaneous bilateral spontaneous hydropneumothorax: a rare presentation of bilateral malignant pleural mesothelioma — H.E. Fayed, V.K. Woodcock, et al. (2013)
• Pleural fluid cytological yield and visceral pleural invasion in patients with epithelioid malignant pleural mesothelioma — V. Pinelli, S. Laroumagne, et al. (2012)
• Dose estimation for internal organs during boron neutron capture therapy for body-trunk tumors — Y. Sakurai, H. Tanaka, et al. (2014)

Browse more research in BMJ Case Reports, or return to medical research.