Miliary mesothelioma: a new clinical and radiological presentation in mesothelioma patients with prolonged survival after trimodality therapy

Our plain-English summary of Miliary mesothelioma: a new clinical and radiological presentation in mesothelioma patients with prolonged survival after trimodality therapy, by L. Purek, S. Laroumagne, H. Dutau, et al (Journal of Thoracic Oncology, 2011).

The study

• Authors: L. Purek, S. Laroumagne, H. Dutau, F. Maldonado, P. Astoul
• Journal: Journal of Thoracic Oncology
• Published: 2011;6(10):1753-6
• Type of article: Case report
• Cited by: 5 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Malignant pleural mesothelioma is usually a fatal disease and is considered a locally aggressive tumor. Consequently, distant metastases are very rare and a diffuse involvement of the lung is seldom reported. However, due to more efficient chemotherapy protocols and aggressive management strategies including induction chemotherapy followed by extrapleural pneumonectomy and adjuvant high-dose hemithoracic radiation therapy, so called trimodality therapy, survival is prolonged in selected patients. Therefore, new presentations of the disease are appearing with new diagnostic and therapeutic challenges. Herein, we report two cases of treated mesothelioma patients who developed a miliary mesothelioma in the remaining lung 36 and 41 months after undergoing multimodal therapy. Diagnostic assessment and therapeutic strategy are discussed taking into account the different evolutions of each patient.

In plain English

This brief report described two men with epithelial malignant pleural mesothelioma treated with trimodality therapy: chemotherapy (cisplatinum and pemetrexed), extrapleural pneumonectomy (surgery removing the lung and pleura on the affected side), and radiation to that side of the chest. Both had occupational asbestos exposure (the first for 10 years; fiber types were not reported) and had smoked. In the first man, aged 71, a CT scan 32 months after completing treatment showed innumerable nodules in a miliary (widely scattered) pattern in the remaining lung. A lymph node biopsy confirmed metastatic epithelial mesothelioma. Despite further chemotherapy, he died 40 months after the diagnosis. The second man, aged 64, showed no sign of recurrence until November 2010. He then had severe breathlessness, a 5-cm nodule under the skin at a former chest tube site, and a miliary pattern in the remaining lung. After six cycles of the same chemotherapy he had no symptoms, needed no oxygen, and the skin nodule had resolved. The authors concluded that physicians should be aware of possible atypical presentations of recurrent mesothelioma after multimodal treatment.

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 (brief report)
• Who was studied: Two men with epithelial malignant pleural mesothelioma treated at the Department of Thoracic Oncology, Hôpital Nord, Marseille, France. One was a 71-year-old man who presented in December 2006 (left side). The other was a 64-year-old man diagnosed in October 2006 (right side).
• Exposure: Occupational asbestos exposure in both men. Case 1 was exposed for 10 years; no duration was given for case 2. No fiber type or job was reported. Both were smokers: 25 pack-years (case 1) and 40 pack-years (case 2).
• Main results:
  • Case 1: after trimodality therapy (three cycles of cisplatinum 75 mg/m2 and pemetrexed 500 mg/m2, left extrapleural pneumonectomy, then 54 Gy in 30 fractions), a CT scan 32 months after completing treatment showed innumerable lung nodules in a miliary distribution, pleural effusion and enlarged mediastinal lymph nodes.
  • Case 1: an endobronchial ultrasound biopsy of mediastinal lymph nodes was diagnosed by the French mesothelioma pathology panel (MESOPATH) as metastatic epithelial mesothelioma.
  • Case 1: despite renewed cisplatinum-pemetrexed chemotherapy and then second-line valproate-doxorubicin, the patient died 40 months after the diagnosis.
  • Case 2: after trimodality therapy completed in May 2007 (three cycles of cisplatinum-pemetrexed, extrapleural pneumonectomy, 55 Gy in 30 fractions), follow-up every 3 months showed no sign of recurrence until November 2010.
  • Case 2: at recurrence the patient had severe dyspnea needing continuous oxygen and a 5-cm subcutaneous nodule at a former chest tube site. CT showed a miliary metastatic pattern in the remaining lung.
  • Case 2: after six cycles of retreatment with cisplatinum-pemetrexed, the patient had ECOG performance status 0, had no symptoms, no longer needed oxygen, and the subcutaneous nodule had completely resolved. He was still being followed every 3 months as of May 2011.
• The authors' conclusion: The authors concluded that physicians should be aware of possible atypical presentations of recurrent malignant pleural mesothelioma during follow-up of patients treated with a multimodal approach. They also stated that the two cases argue for the possibility of spread through the blood or lymphatic system.
• Limitations the authors state:
  • The authors stated that further studies are needed before concluding that patients with recurrent epithelioid mesothelioma are good candidates for retreatment with pemetrexed-based chemotherapy.

Topics

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

Medical terms in this study, explained in our Lexicon: Mesothelioma, Trimodality Therapy, Pleural Mesothelioma, Chemotherapy, Extrapleural Pneumonectomy (EPP), Multimodal Therapy.

Related studies

• Integrated positron emission tomography-computed tomography does not accurately stage intrathoracic disease of patients undergoing trimodality therapy for malignant pleural mesothelioma — J. Pilling, J.A. Dartnell, et al. (2010)
• Survival after trimodality therapy for malignant pleural mesothelioma: Radical Pleurectomy, chemotherapy with Cisplatin/Pemetrexed and radiotherapy — S. Bölükbas, C. Manegold, et al. (2011)
• Improved Outcomes with Modern Lung-Sparing Trimodality Therapy in Patients with Malignant Pleural Mesothelioma — F. Shaikh, M.G. Zauderer, et al. (2017)
• Trimodality therapy for malignant pleural mesothelioma: results from an EORTC phase II multicentre trial — P.E. Van Schil, P. Baas, et al. (2010)
• Trimodality treatment of malignant pleural mesothelioma — H.F. Batirel, M. Metintas, et al. (2008)
• Trimodality management of malignant pleural mesothelioma — G. Maggi, C. Casadio, et al. (2001)

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