Malignant mesothelioma presenting as recurrent hydro-pneumothorax: An atypical case presentation and literature review

Our plain-English summary of Malignant mesothelioma presenting as recurrent hydro-pneumothorax: An atypical case presentation and literature review, by N. Sattar, R. Durrance, A. Khan, et al (Respiratory Medicine Case Reports, 2018).

The study

• Authors: N. Sattar, R. Durrance, A. Khan, N. Patel, M. Mora, A. Shalonov
• Journal: Respiratory Medicine Case Reports
• Published: 2018;23:152-155
• Type of article: Case report
• Cited by: 6 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Malignant Pleural Mesothelioma (MPM) is a rare pleural malignancy, with a vague presentation complicated by a decades-long latency period between environmental exposure and clinical manifestations. Spontaneous hydro-pneumothorax is a rare presentation of MPM, most often requiring invasive tissue biopsy to confirm the etiologic diagnosis. We present the case of 79-year-old male smoker with no documented history of asbestos exposure, who was found to have MPM after presenting with dyspnea and subsequently found to have recurrent hydro-pneumothorax. On Literature review of the limited documented cases of MPM with hydro-pneumothorax, we found an exclusively male population with a significant smoking history, a marked right sided pathology predominance, and a generally poor prognosis. While this corresponds with the examined case, and suggests that the presence of hydro-pneumothorax implies a high-grade tumor and significant tissue invasion, and therefore poor prognosis similar to that of stage 4 disease, it differs from more generalized case reviews of MPM, most importantly in their anatomical descriptions, prognostic indicators, and epidemiologic tendencies.

In plain English

This article reports one patient and reviews earlier published case reports. A 79-year-old man came to a New York emergency department with worsening breathlessness and chest pain. The article describes him as a smoker with no documented history of asbestos exposure. Imaging showed air and fluid around the right lung (a hydro-pneumothorax) and fluid around the left lung. Repeated chest fluid tests found no cancer cells, but the fluid and air kept returning. A pleural biopsy during thoracoscopy, a camera-guided procedure, confirmed epithelioid malignant pleural mesothelioma. The plaques seen were restricted to the chest-wall lining, and biopsies showed no direct invasion, but the authors left lung invasion an open question. Chemotherapy was recommended, but the patient chose comfort care and died 3 months later. The authors reviewed 9 published mesothelioma cases with hydro-pneumothorax. All 9 were men, the authors described a marked smoking history, and all had right-sided involvement. The authors stated that lacking known asbestos exposure does not exclude this diagnosis. They concluded that this presentation is very rare and seems to suggest a higher-grade tumor.

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 one patient with a review of previously published case reports
• Who was studied: One 79-year-old man with high blood pressure and diabetes, described as a smoker, treated at Jamaica Hospital Medical Center in Jamaica, New York. The literature review covered 9 previously published cases.
• Exposure: No known asbestos exposure in the reported patient. In the reviewed cases, the review table listed asbestos for some patients. Other entries were coal particles, industrial factory, unclear, or no exposure.
• Main results:
  • Imaging of the patient showed a right-sided hydro-pneumothorax and a left-sided pleural effusion.
  • Pleural fluid analysis in the patient showed an exudate that was negative for malignant cells.
  • Biopsy confirmed malignant pleural mesothelioma of the epithelioid variant in the patient.
  • Immunohistochemical markers in the patient's biopsy were positive for calretinin, CK 5/6, mesothelin and focal Glut-1.
  • In the patient, the mesothelial plaques observed were restricted to the parietal pleural surface, without chest wall invasion or extension into the pleura on the other side. No direct invasion was found in the biopsy samples. The authors did not rule out invasion of the lung and called it an area for further investigation.
  • The patient chose not to pursue aggressive treatment, received comfort care, and died 3 months later.
  • Among the reviewed published cases, the average age was 67, all were male, a marked tobacco history was noted, and the right chest was involved in every case.
  • The authors stated that the absence of known environmental exposure does not exclude a diagnosis of malignant pleural mesothelioma.
• The authors' conclusion: The authors concluded that malignant pleural mesothelioma presenting as hydro-pneumothorax is very rare. They also concluded that, given the poor prognosis observed, it seems to suggest a higher-grade tumor than previously appreciated.
• Limitations the authors state:
  • Direct invasion of tissue was not seen in the patient's biopsy samples, so the authors stated it cannot be assumed.
  • The authors could find no explanation for the right-sided predominance.

Topics

Medical terms in this study, explained in our Lexicon: Malignant Mesothelioma, Pneumothorax, Pleural Mesothelioma, Latency, Environmental Exposure, Biopsy, Asbestos Exposure, Dyspnea.

Related studies

• Recurrent pneumothorax: an unusual presentation of malignant mesothelioma — S.I. Handa, A.G. Wilkinson (1989)
• Malignant mesothelioma of the tunica vaginalis: a atypical presentation of a rare scrotal tumour — M.C. Harris, C. Logan, et al. (2019)
• Intrapleural talc for the prevention of recurrent pneumothorax — J.R. Milanez, F.S. Vargas, et al. (1994)
• Recurrent pneumothorax following abdominal paracentesis — P.J. Stafford (1990)
• Atypical carcinoid presenting as mesothelioma — P. van Hengel, F. van Geffen, et al. (2001)
• Malignant pleural mesothelioma presenting as spontaneous pneumothorax: a case series and review — S. Alkhuja, A. Miller, et al. (2000)

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