Malignant pleural mesothelioma presenting as a spontaneous pneumothorax

Our plain-English summary of Malignant pleural mesothelioma presenting as a spontaneous pneumothorax, by A. Mitsui, H. Saji, T. Shimmyo, et al (Respirology Case Reports, 2015).

The study

• Authors: A. Mitsui, H. Saji, T. Shimmyo, A. Mochizuki, N. Kurimoto, H. Nakamura
• Journal: Respirology Case Reports
• Published: 2015;3(1):9-12
• Type of article: Case report
• Cited by: 8 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Malignant pleural mesothelioma (MPM) is thought to arise from the mesothelial cells that line the pleural cavities. Most patients initially experience the insidious onset of chest pain or shortness of breath and have a history of asbestos exposure. MPM rarely presents as spontaneous pneumothorax. We report two male patients who presented with a spontaneous hydropneumothorax. One was exposed to asbestos and the other was not. Computed tomography showed tiny nodules with pleural thickness. They both underwent pleural effusion cytology and/or pleural biopsy. Therefore, the pathological diagnosis of MPM was obtained in both cases. We also reviewed 16 Japanese MPM cases with pneumothorax including our two patients. More than half of the patients suffered from pneumothorax repeatedly. We emphasize the need to obtain a pathological diagnosis of pleural effusion cytology and/or pleural biopsy in older patients presenting with a spontaneous hydropneumothorax.

In plain English

This case report described two men in Japan whose malignant pleural mesothelioma first appeared as a spontaneous pneumothorax (a collapsed lung) with fluid in the chest. The first was a 63-year-old air-conditioning maintenance worker with a history of asbestos exposure. A chest tube did not fix the pneumothorax. Mesothelioma was diagnosed from the chest fluid; after surgery, the final diagnosis was epithelioid mesothelioma, stage III. The second was a 57-year-old man who had not been exposed to asbestos. His fluid test was negative, so a pleural biopsy taken through a scope showed epithelial mesothelioma; final pathology after chemotherapy and surgery showed stage II. The authors reviewed 16 Japanese cases of mesothelioma with pneumothorax, including their two. Of these, 13 (81%) were male, four (25%) had a history of asbestos exposure (for four it was unknown), and 11 (69%) had repeated pneumothoraces. The authors found the disease hard to see on CT, especially in the second case. They concluded that a pleural biopsy might be needed in older patients with a spontaneous hydropneumothorax and/or a history of asbestos exposure.

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 two patients, plus a review of published Japanese cases (16 in total, including the two new ones)
• Who was studied: Two male patients treated at St. Marianna University School of Medicine, Japan: a 63-year-old man and a 57-year-old man. The review covered 16 Japanese patients with malignant pleural mesothelioma and spontaneous pneumothorax, reported from 1989 to 2012 plus the two new cases.
• Exposure: Case 1 had worked at an air-conditioning maintenance facility and had a history of asbestos exposure; no fiber type or dose was given. Case 2 had not been exposed to asbestos.
• Main results:
  • Case 1: the pneumothorax did not resolve despite a chest tube. The diagnosis was made by pleural fluid cytology with extra staining, after an earlier cytology result had been negative.
  • Case 1 later underwent right-sided extrapleural pneumonectomy followed by radiotherapy. The final pathological diagnosis was malignant epithelioid pleural mesothelioma, stage III.
  • Case 2, a 57-year-old man not exposed to asbestos: pleural fluid cytology was negative, so a thoracoscopic pleural biopsy was performed. The biopsy diagnosis was epithelial mesothelioma.
  • Case 2 received three cycles of cisplatin and pemetrexed chemotherapy before right-sided extrapleural pneumonectomy. The final pathological diagnosis after surgery was epithelial mesothelioma, stage II.
  • Across the 16 reviewed Japanese cases, the median age was 58 years (range 29 to 80), and 13 (81%) were male.
  • Only four (25%) of the 16 reviewed patients had a history of asbestos exposure. For four earlier-reported patients, exposure history was unknown.
  • Pleural effusion was present in nine (56%) of the 16 reviewed cases.
  • Eleven (69%) of the 16 reviewed patients had repeated pneumothoraces.
  • The authors judged that rupture of necrotic (dead) tumor nodules was the main cause of pneumothorax in their series, leading to recurrent or persistent pneumothorax.
  • In these cases the pleural disease was relatively difficult to detect on CT as well as on chest X-ray, especially in the second case.
• The authors' conclusion: The authors concluded that pleural biopsy might be needed in older patients presenting with a spontaneous hydropneumothorax and/or a history of asbestos exposure.

Topics

Medical terms in this study, explained in our Lexicon: Pleural Mesothelioma, Pneumothorax, Mesothelial Cells, Asbestos Exposure, Pleural Thickness, Pleural Effusion, Cytology, Pleural Biopsy.

Related studies

• Malignant pleural mesothelioma presenting as spontaneous pneumothorax: a case series and review — S. Alkhuja, A. Miller, et al. (2000)
• Lung function 22-35 years after treatment of idiopathic spontaneous pneumothorax with talc poudrage or simple drainage — P. Lange, J. Mortensen, et al. (1988)
• Spontaneous pneumothorax and pulmonary malignant disease--a syndrome sometimes associated with cavitating tumours. Report of nine new cases, four with metastases and five with primary bronchial tumours — F.W. Wright (1976)
• Simultaneous bilateral spontaneous pneumothorax in a patient with peritoneal and pleural papillary mesothelioma — P. Höllinger, D. Gaeng (1997)
• Spontaneous pneumothorax and lung carcinoma: should one consider synchronous malignant pleural mesothelioma? — T.A. Flood, H.S. Sekhon, et al. (2009)
• Pleural granuloma mimicking malignancy 42 years after slurry talc injection for primary spontaneous pneumothorax — S. Tenconi, L. Luzzi, et al. (2010)

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