Pericardial Mesothelioma Presenting as Constrictive Pericarditis

Our plain-English summary of Pericardial Mesothelioma Presenting as Constrictive Pericarditis, by B. Shrestha, R. Handa, B. Poudel, et al (Curēus, 2022).

The study

• Authors: B. Shrestha, R. Handa, B. Poudel, R. Hingorani
• Journal: Curēus
• Published: 2022;14(4):e24270
• Type of article: Case report
• Cited by: 2 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

This case report presents a 60-year-old gentleman with a significant smoking history and possible asbestos exposure who was referred to the emergency department for atrial fibrillation with a rapid ventricular rate and symptoms of heart failure. Labs showed normal brain natriuretic peptide and troponin I. His echocardiography finding suggested constrictive pericarditis with an ejection fraction of 60%. A computed tomography scan was concerning for a pericardial mass. Left and right heart catheterization hinted more toward constrictive physiology; however, some findings were concerning for restrictive physiology. Hence, cardiac magnetic resonance imaging was done, which established the diagnosis of constrictive pericarditis. Pericardiectomy was planned with a maze procedure for atrial fibrillation. However, a malignant neoplasm was seen on a frozen biopsy. Hence, surgery was limited to partial pericardiectomy, as the patient had advanced infiltrative neoplasm that had resulted in constrictive pericarditis. The final pathology report confirmed the diagnosis of malignant pericardial mesothelioma mixed type. Malignancy is usually diagnosed in an advanced stage, like in our case, due to nonspecific initial presentation. A literature review suggests that there is a lack of established consensus on treatment. The response to therapy also seems to be poor and results only in palliation of symptoms, with a median survival of six months from diagnosis despite optimum medical management.

Copyright © 2022, Shrestha et al.

In plain English

This case report described a 60-year-old man, a retired construction worker with reported asbestos exposure and a 40-pack-year smoking history. He was referred to the emergency department with atrial fibrillation and heart failure symptoms. A CT scan showed a mass on the pericardium, the sac around the heart. Fluid drained from around his right lung tested negative for cancer cells. Ultrasound and catheter tests of the heart gave partly conflicting results. An MRI then showed a thickened pericardium that supported constrictive pericarditis, in which a stiff sac restricts the heart. During planned surgery, the pericardium was found densely stuck to the heart, which limited the operation, and a frozen tissue sample showed cancer. Final pathology showed malignant pericardial mesothelioma of mixed epithelioid and sarcomatoid type. He started nivolumab, then chose hospice, and died four months after diagnosis. The authors concluded that this cancer is often diagnosed late because its symptoms are nonspecific, and that a tissue biopsy is needed to diagnose it. Citing earlier publications, they noted there is no established treatment consensus and survival is poor.

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 60-year-old man with chronic diastolic heart failure, permanent atrial fibrillation and alcoholic cirrhosis, an active smoker with a 40-pack-year history. The authors are at Reading Hospital Tower Health (Reading, USA) and AMITA Health Saint Francis Hospital (Evanston, USA); the dates of care are not stated.
• Exposure: Reported asbestos exposure as a retired construction worker; no fiber type, product, or amount is given. He was also an active smoker with a 40-pack-year history.
• Main results:
  • A CT scan of the chest showed a mass on the front, lower part of the pericardium that raised concern for a tumor, along with a moderate to large right pleural effusion.
  • 2800 ml of fluid was drained from around the right lung. The fluid was exudative, and cytology was negative for malignancy.
  • Heart catheterization findings were consistent with constrictive pericarditis, but one finding (pressure tracking of the right and left ventricles) was more consistent with restrictive physiology.
  • Cardiac MRI showed a diffusely thickened, irregular pericardium measuring at most 17 mm, with findings supportive of constrictive pericarditis.
  • At surgery, the thickened pericardium was densely stuck to the heart, which limited the operation. Frozen section showed malignant neoplasm, and histology showed malignant pericardial mesothelioma, mixed epithelioid and sarcomatoid type.
  • Immunostains were positive for pan keratin, vimentin, CK7 and calretinin, an immunoprofile the pathology report called diagnostic of malignant mesothelioma.
  • The patient was started on nivolumab, opted for hospice as his functional status worsened, and died four months after diagnosis.
• The authors' conclusion: The authors concluded that pericardial mesothelioma is often diagnosed late because of nonspecific symptoms, and that a tissue biopsy is needed to establish the diagnosis. Drawing on earlier published work, they said there is no established treatment consensus, response to therapy appears poor, and median survival is about six months from diagnosis.

Topics

Medical terms in this study, explained in our Lexicon: Pericardial Mesothelioma, Asbestos Exposure, Pericardial, Pericardiectomy, Neoplasm, Biopsy, Pathology Report, Median Survival.

Related studies

• Asbestos induced pericardial effusion and constrictive pericarditis — D. Davies, M.I. Andrews, et al. (1991)
• Primary pericardial mesothelioma in a 19-year-old presenting as pericarditis — M.O. Kayatta, S.P. Dineen, et al. (2013)
• Chronic constrictive pericarditis associated with asbestosis — L. Fischbein, M. Namade, et al. (1988)
• Pericardiectomy for treatment of neoplastic constrictive pericarditis — F. Buyukbayrak, E. Aksoy, et al. (2014)
• 18F-FDG PET/CT Revealing Constrictive Pericarditis as the Only Manifestation of Malignant Mesothelioma — J.P. Edel, H. Balink (2019)
• A case of pleural mesothelioma with effusive-constrictive pericarditis — N.A. Weir, B. Gerstenhaber (2001)

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