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Hindawi Publishing Corporation Case Reports in Oncological Medicine Volume 2013, Article ID 198729, 4 pages http://dx.doi.org/10.1155/2013/198729 Case Report Pleural Mesothelioma Presenting as Periumbilical Metastasis: The First Clinical Documentation 1 1 2 R. F. Falkenstern-Ge, M. Kimmich, S. Bode-Erdmann, 3 4 1 G. Friedel, G. Ott, and M. Kohlhäufl Division of Pulmonology, Klinik Schillerhoehe, Center for Pulmonology and or Th acic Surgery, Teaching Hospital of the University of Tuebingen, Solitude Street 18, Gerlingen, 70839 Stuttgart, Germany Division of Pathology, Robert Bosch Krankenhaus, Teaching Hospital of the University of Tuebingen, Auerbachstrasse 110, 70376 Stuttgart, Germany Division of oTh racic Oncology, Klinik Schillerhoehe, Center for Pulmonology and oTh racic Surgery, Teaching Hospital of the University of Tuebingen, Solitude Street 18, Gerlingen, 70839 Stuttgart, Germany Division of Clinical Pathology, Robert Bosch Krankenhaus, Teaching Hospital of the University of Tuebingen, Auerbachstrasse 110, 70376 Stuttgart, Germany Correspondence should be addressed to R. F. Falkenstern-Ge; email@example.com Received 12 March 2013; Accepted 1 April 2013 Academic Editors: S. B. Chichareon, C. Gennatas, C. V. Reyes, M. Romkes, and Y. Yokoyama Copyright © 2013 R. F. Falkenstern-Ge et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Introduction. Pleural mesothelioma with metastasis to the subcutaneous tissue of the abdominal wall at first diagnosis and without penetration into the peritoneum is an extremely rare clinical presentation. Methods. Patients with pleural mesothelioma have low survival rate. Usually, the disease at presentation is confined to its site of origin (most oen ft the pleural cavity). A 55-year-old man was referred to our center due to increasing dyspnea and a painful periumbilical mass in the anterior abdominal wall. CT scan revealed both advanced mesothelioma of the pleura and a tumor mass confined to the subcutaneous fatty tissue without penetration through the peritoneum. Results. Video-assisted thoracoscopy confirmed the diagnosis of epithelioid pleural mesothelioma, which was also confirmed by a biopsy of the periumbilical mass. Systemic chemotherapy with cisplatin and pemetrexed was initiated. Under the ongoing systemic chemotherapy, the evaluation revealed partial remission of pleura mesothelioma and its subcutaneous manifestation of the abdominal wall. Conclusion. Mesothelioma of the pleura with a simultaneous metastasis to the subcutaneous fatty tissue of the abdominal wall at presentation without penetration of peritoneum is a rare clinical presentation of mesothelioma disease. The knowledge of its natural history is very limited. This is the first ever clinical documentation of a patient with pleura mesothelioma and simultaneous subcutaneous manifestation of abdominal wall. 1. Main Article (Figures 1(a) and 1(b)). Video assisted thoracoscopy biop- sies and biopsy of the periumbilical mass confirmed the A 55-year-old nonsmoker with a large pleural effusion at histological diagnosis of epitheloid pleural mesothelioma the right side was urgently referred to our center. He (cT3N1 M1) with infiltration of the pleura and a simultaneous was occupied as a construction worker in the shipbuild- subcutaneous tissue metastasis of the abdominal wall without ing industry for a long time with asbestos exposure. He penetration into the peritoneum. complained about increasing severe dyspnea and great Due to the abdominal wall metastasis of the patient abdominal pain. During initial physical examination we (cT3N1 M1), surgical option was not indicated. We ini- found a palpable periumbilical mass. The initial CT scan tiated systemic chemotherapy with cisplatin and peme- revealed pleural mesothelioma with right-sided effusion and trexed. eTh chemotherapy was well tolerated. Reevaluation a tumor mass in the abdominal subcutaneous fatty tissue with CT scan after 6 cycles of cisplatin and pemetrexed (10 cm× 7 cm) without penetration through the peritoneum also showed partial remission of the pleural mesothelioma 2 Case Reports in Oncological Medicine (a) (b) Figure 1: (a) CT scan shows a pleural effusion; the surface of the right lung is colonized and infiltrated by pleural mesothelioma. (b) Large tumor mass of the abdominal wall (10× 7 cm) without penetration into the peritoneum. (a) (b) Figure 2: (a) Tumor manifestation before the systemic chemotherapy, ( b) partial remission of the tumor in the right lung after 6 cycles of chemotherapy. (Figures 2(a) and 2(b)) and remission of the manifesta- Examination of a punch biopsy from the abdominal mass tion in the abdominal wall (Figures 3(a) and 3(b)). The revealed an identical tumor as seen in the pleural biopsies clinical conditioning of our patient improved clearly under (Figure 4(c)). chemotherapy; he was again partially employable. 3. Discussion Malignant mesothelioma is a neoplasm originating from the 2. Histopathology mesothelial cells lining human body cavities. Mesotheliomas Histopathological examination of biopsies gained on occa- are aggressive tumors arising from various serous surfaces sionofthevideo-assistedthoracoscopyshowedaninfiltration such as the pleura (65%–70%), peritoneum (30%), tunica of thepleural fattytissuebycohesivemedium-sizedcells with vaginalis testis, or pericardium (1%-2%) [1, 2]. There is a long round even nuclei (Figure 4(a)). latency period between first exposure to asbestos and the Immunohistochemistry proved the cells to express CK7, diagnosis of mesothelioma that is rarely less than 15 years CK5/6, calretinin (Figure 4(b)), and WT1, whereas EA, TTF1, and oeft n exceeds 30 years [ 3, 4]. The natural history of and Napsin were negative. Therefore, a diagnosis of malignant malignant pleural mesothelioma shows a median survival of 4 mesothelioma was rendered. to 12 months of patients without intervention [5–7]. However, Case Reports in Oncological Medicine 3 (a) (b) Figure 3: (a) Large subcutaneous metastasis of the abdominal wall before chemotherapy, (b) remission of the subcutaneous metastasis after 6 cycles of chemotherapy. (a) (b) (c) Figure 4: (a) eTh H&E staining ((a) ×200) of the pleural tumor. (b) eTh immunohistochemistry ((b) ×200) of the pleural tumor. (c) eTh abdominal tumor (H&E×100). long-term survivors have been reported with a survival time In case of a pleural mesothelioma with peritoneal pene- of up to 19 years [2, 8]. tration, systemic chemotherapy with simultaneous intraperi- As to the M staging, mesotheliomas have a lower toneal chemotherapy is considered to be the most eeff ctive rate of metastasis compared to non-small-cell-lung cancer therapeutic option . Intraperitoneal chemotherapy can (NSCLC), for example, into the cerebrum. Moreover, NSCLC be instilled aeft r surgery or without surgery through an metastasizes also more frequently into the skeleton, the kid- abdominal catheter. At present, intraperitoneal application of neys, and the adrenal glands, whereas metastases of pleural cisplatin, doxorubicin, and paclitaxel combined with cytore- mesotheliomas present more oeft n as a diffuse peritoneal ductive surgery is recommended . carcinosis . 4 Case Reports in Oncological Medicine Cisplatin is the most studied agent for pleural mesothe-  M. Scharmach, V. Neumann, K. M. Muller ¨ , and M. Fischer, “Comparison of patterns of metastasis between malignant pleu- lioma with or without peritoneal manifestations, which ralmesotheliomas andpulmonary carcinomas,” Pneumologie, shows antitumor activity in 25% of patients . Systemic vol. 60, no. 5, pp. 277–283, 2006. chemotherapy with pemetrexed in combination with cis-  A. Bridda, I. Padoan, R. Mencarelli, and M. Frego, “Peritoneal platin has shown survival improvement in patients with mesothelioma: a review,” Medscape General Medicine,vol.9,no. pleural mesothelioma [12, 13]. 2, p. 32, 2007. Metastasis of mesothelioma of the pleura to the sub-  B. J. Park, H. R. Alexander, S. K. Libutti et al., “Treatment of cutaneous tissue is an extremely rare occurrence. Patel et primary peritoneal mesothelioma by continuous hyperthermic al.reportedona25-year-oldwoman,who hadundergone peritoneal perfusion (CHPP),” Annals of Surgical Oncology,vol. chemotherapy, partial excision of tumor followed by radio- 6, no. 6, pp. 582–590, 1999. therapy of mesothelioma of the pleura, presented three  D. T. Le,M.Deavers,K.Hunt, A. Malpica,and C. F. Ver- months later with painless widespread subcutaneous nodules, schraegen, “Cisplatin and irinotecan (CPT-11) for peritoneal histologically being diagnosed as metastases of mesothelioma mesothelioma,” Cancer Investigation,vol.21, no.5,pp. 682–689, of the pleura . It is worth to be mentioned that those sub- cutaneous metastases were not simultaneous to the primary  R. Garcia-Carbonero and L. Paz-Ares, “Systemic chemotherapy pleural mesothelioma during the first diagnosis. in the management of malignant peritoneal mesothelioma,” To our knowledge of the current literature, this is the rfi st European Journal of Surgical Oncology,vol.32, no.6,pp. 676– reported clinical documentation of a pleural mesothelioma 681, 2006. with a simultaneous solitary subcutaneous tissue metastasis  T. Patel, R. Bansal,P.Trivedi,L.Modi, andM.J.Shah, “Sub- of the abdominal wall without penetration of peritoneum at cutaneous metastases of sarcomatoid mesothelioma with its the time of diagnosis. differential diagnosis on fine needle aspiration—a case report,” Indian JournalofPathology andMicrobiology,vol.48, no.4,pp. 482–484, 2005. Conflict of Interests The authors indicated no potential conflict of interests. References  D. M. Belekar, A. A. Desai, V. V. Dewoolkar, J. R. Anam, andM.B.Parab,“An unusualcaseofprimary peritoneal mesothelioma,” eTh Internet Journal of Surgery ,vol.20, no.1,p. 4, 2009.  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Case Reports in Oncological Medicine – Hindawi Publishing Corporation
Published: Apr 18, 2013
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