A Pleural effusion with a story to tell: A rare case of malignant mesothelioma

Authors' Affiliations

Muhammad Raafey MD,Department of Pathology, East Tennessee State University Sashki Singal, MD,Division of Oncology-Hematology, Department of Medicine, East Tennessee State University Kanishka Chakraborty, MD,Division of Oncology-Hematology, Department of Medicine, East Tennessee State University

Location

D.P. Culp Center Ballroom

Start Date

4-5-2024 9:00 AM

End Date

4-5-2024 11:30 AM

Poster Number

99

Name of Project's Faculty Sponsor

Kanishka Chakraborty

Faculty Sponsor's Department

Medical Education

Classification of First Author

Medical Resident or Clinical Fellow

Competition Type

Competitive

Type

Poster Presentation

Presentation Category

Health

Abstract or Artist's Statement

Malignant mesothelioma is a rare malignancy arising from the mesothelial cells surrounding the pleura that occurs with exposure to asbestos. Occupational exposure to asbestos is known in the manufacturing industry for its insulating properties and low cost until its use was regulated following studies demonstrating its carcinogenic properties. People who had been previously exposed to this carcinogen may be at increased risk for developing malignant mesothelioma. We present an 81-year-old female with past medical history of ovarian cancer, chronic obstructive pulmonary disease, and chronic smoking who presented with worsening chest pain and shortness of breath. She had previously required multiple thoracentesis from which pleural fluid had been negative for malignancy. Patient also had mediastinal adenopathy for which she underwent a bronchoscopy by pulmonology with biopsies that were non-diagnostic. On initial evaluation, she was noted to have an increased right-sided pleural effusion for which she underwent a repeat thoracentesis and pleural fluid was positive for atypical mesothelial cells. Immunohistochemistry demonstrated that the cells were positive for WT1, calretinin, and negative for TTF-1, MOC-32, and CD163. Given negative thyroid transcription factor 1 (TTF-1), a known marker for lung malignancy, a primary lung tumor was less likely. Case was discussed with cardiothoracic surgery who proceeded with pleural biopsy and talc pleurodesis. Upon gross inspection of the pleural cavity, noted findings of both gross disease located in the parietal and visceral pleura. Pleural biopsy findings were consistent with malignant mesothelioma, epithelioid subtype. Upon further questioning, patient reported working for 30 years in a textile company making leather seats for cars. Cardiothoracic surgery deemed the patient not a surgical candidate given chronic oxygen requirement and multiple co-morbidities. Plans for systemic treatment with Pemetrexed based chemotherapy versus dual immune-checkpoint inhibitor therapy in the palliative setting were discussed with the patient. Initiation of treatment as outpatient is currently pending patient’s final decision regarding her wish to pursue further treatment for her underlying malignancy. Malignant mesothelioma is thought to occur as a result of chronic inflammation from exposure to asbestos. It has a very poor prognosis with a 5-year survival rate of 12%. Malignant pleural effusions can be the initial clinical presentation in more than 90% of patients with mesothelioma. Surgery can occur in the curative setting, although most patients present with more advanced disease. Chemotherapy with Cisplatin and Pemetrexed was previously done in the frontline setting. Emerging data regarding the use of Nivolumab plus Ipilimumab in patients with untreated unresectable malignant pleural mesothelioma demonstrated meaningful improvements in overall survival when compared to standard of care chemotherapy which has led to supporting this treatment in the frontline setting with hopes for better tolerability and improved survival data in the future. Environmental exposure to asbestos can lead to malignant mesothelioma. Recurrent unexplained pleural effusions without clear etiology should raise suspicion for malignancy and may warrant further workup with a pleural biopsy. It is essential to further assess any possible occupational exposure that might further contribute to the diagnosis of malignant mesothelioma.

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Apr 5th, 9:00 AM Apr 5th, 11:30 AM

A Pleural effusion with a story to tell: A rare case of malignant mesothelioma

D.P. Culp Center Ballroom

Malignant mesothelioma is a rare malignancy arising from the mesothelial cells surrounding the pleura that occurs with exposure to asbestos. Occupational exposure to asbestos is known in the manufacturing industry for its insulating properties and low cost until its use was regulated following studies demonstrating its carcinogenic properties. People who had been previously exposed to this carcinogen may be at increased risk for developing malignant mesothelioma. We present an 81-year-old female with past medical history of ovarian cancer, chronic obstructive pulmonary disease, and chronic smoking who presented with worsening chest pain and shortness of breath. She had previously required multiple thoracentesis from which pleural fluid had been negative for malignancy. Patient also had mediastinal adenopathy for which she underwent a bronchoscopy by pulmonology with biopsies that were non-diagnostic. On initial evaluation, she was noted to have an increased right-sided pleural effusion for which she underwent a repeat thoracentesis and pleural fluid was positive for atypical mesothelial cells. Immunohistochemistry demonstrated that the cells were positive for WT1, calretinin, and negative for TTF-1, MOC-32, and CD163. Given negative thyroid transcription factor 1 (TTF-1), a known marker for lung malignancy, a primary lung tumor was less likely. Case was discussed with cardiothoracic surgery who proceeded with pleural biopsy and talc pleurodesis. Upon gross inspection of the pleural cavity, noted findings of both gross disease located in the parietal and visceral pleura. Pleural biopsy findings were consistent with malignant mesothelioma, epithelioid subtype. Upon further questioning, patient reported working for 30 years in a textile company making leather seats for cars. Cardiothoracic surgery deemed the patient not a surgical candidate given chronic oxygen requirement and multiple co-morbidities. Plans for systemic treatment with Pemetrexed based chemotherapy versus dual immune-checkpoint inhibitor therapy in the palliative setting were discussed with the patient. Initiation of treatment as outpatient is currently pending patient’s final decision regarding her wish to pursue further treatment for her underlying malignancy. Malignant mesothelioma is thought to occur as a result of chronic inflammation from exposure to asbestos. It has a very poor prognosis with a 5-year survival rate of 12%. Malignant pleural effusions can be the initial clinical presentation in more than 90% of patients with mesothelioma. Surgery can occur in the curative setting, although most patients present with more advanced disease. Chemotherapy with Cisplatin and Pemetrexed was previously done in the frontline setting. Emerging data regarding the use of Nivolumab plus Ipilimumab in patients with untreated unresectable malignant pleural mesothelioma demonstrated meaningful improvements in overall survival when compared to standard of care chemotherapy which has led to supporting this treatment in the frontline setting with hopes for better tolerability and improved survival data in the future. Environmental exposure to asbestos can lead to malignant mesothelioma. Recurrent unexplained pleural effusions without clear etiology should raise suspicion for malignancy and may warrant further workup with a pleural biopsy. It is essential to further assess any possible occupational exposure that might further contribute to the diagnosis of malignant mesothelioma.