Malignant Mesothelioma: Overcoming Diagnostic Hurdles

Our plain-English summary of Malignant Mesothelioma: Overcoming Diagnostic Hurdles, by P.D. R, S. Grace Priyadarshini, J. P (Curēus, 2024).

The study

• Authors: P.D. R, S. Grace Priyadarshini, J. P
• Journal: Curēus
• Published: 2024;16(9):e68718
• Type of article: Case report
• Cited by: 1 article, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Malignant pleural mesothelioma, an aggressive neoplasm frequently linked to asbestos exposure, is often detected at an advanced stage. This report details the case of a 58-year-old mason who presented with left-sided chest pain, and shortness of breath, accompanied by weight loss for a month. A positron emission tomography (PET) scan revealed increased uptake along the pleural surface, as well as in several mediastinal lymph nodes and the left supraclavicular lymph node. Thoracoscopy revealed the presence of multiple nodules on the costal pleura. Despite repeated negative results from pleural effusion cytology, cell block analysis, and pleural biopsies, the diagnosis of malignant mesothelioma (MM) was ultimately established through an ultrasound-guided (USG) biopsy of the left supraclavicular lymph node, with immunohistochemical confirmation using calretinin.

Copyright © 2024, R et al.

In plain English

This case report describes one patient, a 58-year-old male mason who had smoked for 20 years. He had one month of left-sided chest pain, breathlessness, and loss of weight and appetite, with a large fluid collection around the left lung. Scans showed nodular pleural thickening and enlarged lymph nodes, including one above the left collarbone. Thoracoscopy found multiple nodules on the pleura, but repeated pleural fluid tests, cell blocks and pleural biopsies showed no cancer cells. A needle biopsy of the lymph node above the collarbone stained positive for calretinin and negative for TTF-1, and led to a final diagnosis of high-grade epithelioid mesothelioma. He began palliative chemotherapy with pemetrexed and carboplatin. The article does not report confirmed asbestos exposure. The authors wrote that he likely had it because of his long construction career. They noted that a sample from a site the cancer had spread to may not fully reflect the original tumor. The authors concluded that a metastatic lymph node, if present, can provide diagnostic clarity.

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 58-year-old male mason with left-sided pleuritic chest pain, breathlessness, and weight and appetite loss for one month; a smoker for 20 years. The authors are from the Department of Pathology, Saveetha Medical College and Hospital, Chennai, India. No dates of care are given.
• Exposure: Prolonged exposure to construction materials during a career in construction. The authors considered asbestos exposure likely, but no fiber type, product or measured dose is reported. The patient had also smoked for 20 years.
• Main results:
  • CT scan showed nodular pleural thickening and a few enlarged lymph nodes in the pre-tracheal and left supraclavicular regions. PET scan showed increased uptake along the pleural surface, in multiple mediastinal lymph nodes and in a left supraclavicular lymph node.
  • Thoracoscopy found multiple nodules in a hemorrhagic background along the costal pleural surface.
  • The thoracoscopy-guided pleural biopsy, examined at multiple deeper levels, showed no malignant cells. Repeated pleural fluid analyses and cell block were all negative for malignant cells.
  • Ultrasound-guided fine needle aspiration of the left supraclavicular lymph node showed features of metastatic carcinomatous deposits. A tru-cut biopsy of the same node could not give a definitive diagnosis on its own.
  • Immunohistochemistry on the lymph node biopsy was diffusely positive for calretinin and negative for TTF-1.
  • The final diagnosis was high-grade epithelioid mesothelioma with trabecular and adenomatoid patterns, with six mitoses per 10 high-power fields and no necrosis.
  • The patient was clinically diagnosed with left metastatic malignant mesothelioma. He completed a second cycle of palliative chemotherapy with pemetrexed and carboplatin and remained under follow-up.
• The authors' conclusion: The authors concluded that diagnosing malignant mesothelioma from a pleural biopsy is often difficult and that even when tissue is obtained, the sample may not come from a representative site. In such cases, a metastatic lymph node, if present, can provide diagnostic clarity.
• Limitations the authors state:
  • The tumor features may not fully represent the primary tumor, because the biopsy came from a metastatic site. The authors included it because it was the only histologic diagnosis available for the patient.

Topics

Medical terms in this study, explained in our Lexicon: Malignant Mesothelioma, Pleural Mesothelioma, Neoplasm, Asbestos Exposure, Mediastinal Lymph Nodes, Thoracoscopy, Pleura, Pleural Effusion.

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