Spontaneous diaphragmatic rupture following neoadjuvant chemotherapy and cytoreductive surgery in malignant pleural mesothelioma: A case report and review of the literature

Our plain-English summary of Spontaneous diaphragmatic rupture following neoadjuvant chemotherapy and cytoreductive surgery in malignant pleural mesothelioma: A case report and review of the literature, by M. Cattaneo, P. Mendogni, F. Damarco, et al (International Journal of Surgery Case Reports, 2020).

The study

• Authors: M. Cattaneo, P. Mendogni, F. Damarco, D. Tosi
• Journal: International Journal of Surgery Case Reports
• Published: 2020;77S(Suppl):S85-S87
• Type of article: Case report
• Cited by: 2 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Introduction: Diaphragmatic rupture (DR) is an acquired diaphragmatic defect that can cause herniation of abdominal organs into the chest. It is usually a trauma-related lesion, but rarely it can occur spontaneously. Every DR with abdominal herniation should be considered a surgical emergency.

Presentation Of Case: A 61-year-old male patient, with previous exposure to asbestos, was diagnosed of Stage Ib malignant pleural mesothelioma (MPM). He underwent neo-adjuvant chemotherapy (three cycle of cisplatin-pemetrexed combination) and a cytoreductive surgery with pleurectomy/decortication. Post-operative course was characterized by prolonged air-leakage (PAL). After three months, during a follow-up CT-scan, a spontaneous diaphragmatic rupture (SDR) with gastric herniation was detected and treated by a laparascopic diaphragmatic repair and suture.

Discussion: Spontaneous diaphragmatic rupture (SDR) is an extremely rare injury of the diaphragm (less than 1% of all DR). In this case, potential predisposing factors for SDR could be: presence of diaphragmatic "locus minoris resistentiae" due to thinning of the diaphragm and increase tissue fragility after neo-adjuvant chemotherapy and diaphragmatic pleural stripping; increased thoraco-abdominal pressure gradient due to PAL and residual pleural space. Thus, we confirmed the feasibility and safety of the laparoscopic approach.

Conclusion: We highlight the multifactor etiopathology, the challenging diagnosis and the importance of a prompt treatment of SDR.

Copyright © 2020 The Authors. Published by Elsevier Ltd.. All rights reserved.

In plain English

This case report, from Milan, Italy, describes one 61-year-old man with previous asbestos exposure. The article gives no details of the asbestos type or how the exposure occurred. In 2019 the patient was diagnosed with left-sided malignant pleural mesothelioma, epithelioid subtype, Stage Ib. After three cycles of chemotherapy with cisplatin and pemetrexed, a PET scan showed a complete metabolic pleural response. In November 2019 surgeons removed the pleura (pleurectomy/decortication), including stripping it from the left diaphragm while keeping the diaphragm muscle intact. Three months later the patient had difficulty swallowing and reflux, and a CT scan showed a 4.5 cm tear in the diaphragm with the stomach pushed into the chest. Two weeks later the tear was repaired by emergency laparoscopic surgery, and the patient went home on day 4. In June 2020 the diaphragm was intact and the cancer stable. The authors suggested that the chemotherapy, the pleural stripping, a prolonged air leak after surgery and the remaining pleural space may together have led to the rupture. They described this as the first reported case of its kind. It describes one patient, not how often this happens.

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 a single patient, with a brief discussion of published literature
• Who was studied: One 61-year-old male patient with suspected malignant pleural mesothelioma, referred to a thoracic surgery department in Milan, Italy; treated and followed from 2019 to June 2020
• Exposure: Previous asbestos exposure is stated, with no fiber type, job or dose given. The case concerns complications after mesothelioma treatment: three cycles of cisplatin-pemetrexed chemotherapy followed by pleurectomy/decortication.
• Main results:
  • The patient's tissue diagnosis was malignant pleural mesothelioma, epithelioid subtype, Stage Ib (pT3N0)
  • The patient received three cycles of chemotherapy before surgery, after which FDG-PET showed a complete metabolic pleural response
  • In November 2019 the patient underwent cytoreductive surgery with pleurectomy/decortication, including complete stripping of the left diaphragmatic pleura with the diaphragm muscle preserved
  • Recovery after surgery was complicated by a prolonged air leak that resolved on its own; the chest tube was removed on day 20
  • Three months later a CT scan found a 4.5 cm tear on the posterior left crus of the diaphragm, with the stomach herniated into the chest and no sign of incarceration
  • Two weeks later, after vomiting and epigastric pain, the hernia was reduced and the tear repaired with direct suture by emergency laparoscopic surgery
  • The patient was discharged without complications on day 4 after the repair
  • At follow-up in June 2020 the diaphragm was intact and the cancer burden was stable and controlled
  • The authors stated this was the first reported case of spontaneous diaphragmatic rupture in a mesothelioma patient treated by chemotherapy and cytoreductive surgery
• The authors' conclusion: The authors suggested that chemotherapy and the surgery (with stripping of the diaphragmatic pleura) could have thinned the diaphragm and made the tissue more fragile. They suggested that the prolonged air leak and the remaining pleural space may then have upset the pressure balance between abdomen and chest, leading to the rupture. They emphasised a multidisciplinary, specialised approach to diaphragmatic rupture.

Topics

Medical terms in this study, explained in our Lexicon: Neoadjuvant Chemotherapy, Cytoreductive Surgery, Pleural Mesothelioma, Chemotherapy, Cisplatin, Pemetrexed (Alimta), Pleurectomy/Decortication (P/D), Diaphragm.

Related studies

• Long term survival and perioperative propensity score matched outcomes of diaphragmatic resections compared to stripping in cytoreductive surgery + intra-peritoneal chemotherapy — B. Singh, G. Singh, et al. (2020)
• Thoracic complications in patients undergoing intraperitoneal heated chemotherapy with mitomycin following cytoreductive surgery — M.Y. Chen, C. Chiles, et al. (1997)
• Abdominal Wall Morbidity Following Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy — F. Struller, I. Koenigsrainer, et al. (2017)
• Commentary: Cisplatin-induced nephrotoxicity following cytoreductive surgery and heated intraoperative chemotherapy for malignant pleural mesothelioma — S.S. Groth, R.T. Ripley (2021)
• Treating peritoneal mesothelioma with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. A case series and review of the literature — K. Stamou, D. Tsamis, et al. (2015)
• Types of surgery post-neoadjuvant chemotherapy for pleural mesothelioma — K. Kuribayashi, H. Doi, et al. (2019)

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