Introduction: Malignant mesothelioma is a rare aggressive cancer that can arise from the membranes of several organs. Malignant pleural mesothelioma (MPM) makes up 94% of the 3000 new cases of mesothelioma diagnosed every year in the United States.  Clinically, MPM presents with nonspecific symptoms of progressive dyspnea, cough, pleural effusion and occasionally weight loss. While local invasion has been noted before, distant metastasis is rare. MPM has a broad range of clinical manifestations, leading to lower detections rates and advanced-stage diagnoses. Here we present a unique presentation of MPM highlighting importance of early clinical detection of this rare cancer. 

Case Presentation: Patient is a 70-year-old female with past medical history of breast cancer status post lumpectomy who presented to outpatient clinic for insidiously worsening sharp right-sided chest pain for about a year. She sought treatment from multiple physicians and chiropractors for pain management, but noted little improvement. The patient was diagnosed with zoster sine herpeti (internal shingles) and treated with gabapentin for post-herpetic neuralgia with minor improvement in symptoms. Of note, patient lost over 30 pounds during this year, which she attributed to loss of appetite and persistent pain. 

Imaging of patient’s chest revealed a pleural effusion and she was scheduled for a thoracentesis. The procedure was complicated by a hydropneumothorax, which was then treated with a chest tube. Patient subsequently underwent video-assisted thoracoscopic surgery (VATS), which revealed a thickened pleura. 

Final/Working Diagnosis: Pleural biopsy showed malignant pleural mesothelioma (MPM) of the biphasic histologic subtype. CT scan of the chest confirmed mass extension throughout the R pleura and invasion into the ribs. 

Management/Outcome/Follow-up: Patient was admitted was to in-patient medicine team for pain management and goals of care discussion. Vitals signs were remarkable for persistent tachycardia. On physical exam, patient was cachectic with fluctuating mental status. Multimodal pain control was started with pregabalin and hydromorphone PCA, but patient continued to experience unbearable pain. 

Multiple pain management regimens were attempted over the course of a month of in-patient treatment. Eventually, an intrathecal pump alleviated the pain considerably. After an extensive goals of care discussion, the patient decided to pursue hospice care.

References:

1. Beebe-Dimmer JL, Fryzek JP, Yee CL, Dalvi TB, Garabrant DH, Schwartz AG, Gadgeel S. Mesothelioma in the United States: a Surveillance, Epidemiology, and End Results (SEER)-Medicare investigation of treatment patterns and overall survival. Clin Epidemiol. 2016 Oct 26;8:743-750. doi: 10.2147/CLEP.S105396. PMID: 27822122; PMCID: PMC5087771. 
2. Benjamin Wadowski ; Yin P. Hung; Assunta De Rienzo. Malignant pleural mesothelioma subtypes. Atlas Genet Cytogenet Oncol Haematol. 2019-12-01