History of Present Illness
A 67-year-old Caucasian man went to his general practitioner because of mild exertional dyspnea. Physical examination revealed reduction in respiratory sounds in the lower right hemithorax. Chest radiography showed homogeneous right opacity with blunting of the costophrenic angle, suggestive of pleural effusion ( Fig. 2.1 ). Empiric antibiotic therapy (amoxicillin 1 g two times daily) was prescribed for a week. One month later, chest radiography showed unchanged findings. The patient was then sent to the pulmonology department and admitted for further investigations.
Past Medical History
The patient did not have any prior medical problems and was a lifetime nonsmoker. About 30 years earlier, he had worked for about 3 years as a carpenter in close contact with flaked asbestos leaves; later he had worked as a plumber for 30 years, with possible further sporadic contact with asbestos. No family members had respiratory diseases. The patient did not routinely take any drugs.
Physical Examination and Early Clinical Findings
At admission, the patient was afebrile, alert, and cooperative, with slight respiratory symptoms at rest. Oxygen saturation measured with pulse oximetry was 95% on room air, heart rate was 78 beats/min, respiratory rate was 16 breaths/min, and blood pressure was 120/80 mm Hg. On chest examination, breath sounds were greatly reduced in the lower right hemithorax. No pallor, clubbing, or peripheral edema was observed. Chest ultrasonography ( Fig. 2.2 ) and chest computed tomography (CT) ( Fig. 2.3 ) confirmed right-sided pleural effusion and revealed bilateral pleural plaques.
Clinical Course
Because of the modest pleural effusion and the history of asbestos exposure, the medical team opted for diagnostic medical thoracoscopy, not preceded by thoracentesis or thoracic drainage. Thoracoscopy showed diffuse pleural plaques and nodules ( Fig. 2.4 ). Several biopsies of the parietal pleura were performed. Histological examination revealed hyalinized collagen plaques and large areas of stromal invasion by epithelioid malignant pleural mesothelioma (MPM) with the following immunohistochemical pattern: calretinin positive, epithelial membrane antigen (EMA) positive, thyroid transcription factor 1 (TTF-1) negative, epithelial cell adhesion molecule (Ber-EP4) negative; carcinoembryonic antigen (CEA) negative ( Fig. 2.5 ). After thoracoscopy, a drainage tube was maintained for 8 days. Subsequently talc slurry pleurodesis via chest tube was performed to reduce the risk of recurrence of pleural effusion.
Recommended Therapy and Further Indications at Discharge
The patient was discharged with prescribed analgesic therapy (paracetamol). The case was discussed in a multidisciplinary team meeting. Because the patient had World Health Organization [WHO] performance status 1 (= good), surgical management (pleurectomy/decortication) was proposed. The patient was made aware of the uncertain benefit of surgery on survival and its potential impact on quality of life, and he declined surgical intervention. Thus first-line chemotherapy with pemetrexed plus cisplatin was proposed.
Follow-Up and Outcomes
The patient underwent six cycles of pemetrexed 500 mg/m 2 plus cisplatin 75 mg/m 2 , administered once every 21 days. During chemotherapy, he also received folic acid (600 μg per day orally) and vitamin B 12 (1000 μg every 9 weeks, intramuscularly). Dexamethasone was also administered on the days immediately before, including, and after pemetrexed dosing to reduce the risk of severe skin rash.
The patient’s disease was stable for 9 months; however, new right pleural lesions were detected subsequently, with development of increasing pain, cachexia, and progressive dyspnea. He died 3 months later as a result of a massive pulmonary embolism.
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