Successful treatment of simultaneous malignant pleural mesothelioma and pulmonary adenocarcinoma: A case report

Abstract

The present report described the case of a 74-year-old male patient with asbestos exposure whose chest computed tomography revealed a right lower lobe nodule and right pleural effusion. Pleural biopsy led to the diagnosis of epithelial malignant pleural mesothelioma (cT2N0M0, stage IB). Combination therapy with cisplatin + pemetrexed led to the complete remission of malignant pleural mesothelioma; however, the right lower lobe nodule grew in size over time. The patient was subsequently diagnosed with lung adenocarcinoma (cT1aN0M0, stage IA1) by computed tomography-guided biopsy performed 18 months after chemotherapy initiation and achieved remission of lung adenocarcinoma with stereotactic radiotherapy. The patient was alive without recurrence at the 12-month follow-up. The present case illustrated that multiple active regimens are currently available for malignant pleural mesothelioma and lung cancer that can aid in the treatment of complex cases.

Keywords: asbestos; cisplatin; lung cancer; malignant pleural mesothelioma; pemetrexed.

Figure 1.

Initial imaging of the patient. (A) Chest X-ray showed blunting of the right costophrenic angle and computed tomography showed (B) partial thickening of the right pleura (green arrows) and (C) right pleural effusion and nodules along the right interlobar pleura (red arrow).

Figure 2.

Pleural fluid cytology. (A) Papillary and glandular mass with prominent nucleoli and partial multinucleation on Papanicolaou stain (magnification, ×40). (B) Hematoxylin and eosin staining of cell block (magnification, ×10). (C) Periodic acid Schiff staining of cell block (magnification, ×10). Evaluation of the cell block by immunohistochemistry revealed atypical cells, which were positive for (D) CK7 (magnification, ×10), (E) CK5/6 (magnification, ×10), (F) calretinin (magnification, ×10) and (G) mesothelin (magnification, ×10), and negative for (H) CK20 (magnification, ×10), (I) CDX2 (magnification, ×10), (J) napsin A (magnification, ×10) and (K) p40 (magnification, ×10). CK, cytokeratin.

Figure 3.

Findings from the thoracoscopic biopsy. (A) Thoracoscopy revealed a nodule in the right dorsolateral pleura, and at a magnification of (B) ×40, epithelioid malignant mesothelioma was observed in the resected specimen stained with hematoxylin and eosin. Immunostaining demonstrated that the specimen was positive for (C) calretinin, (D) keratin AE1/AE3, (E) CAM 5.2, (F) podoplanin (D2-40) and (G) epithelial membrane antigen; however, the basal surface was only mildly positive for (H) epithelial cell adhesion molecule/MOC-31. The specimen was negative for (I) thyroid transcription factor-1 and (J) carcinoembryonic antigen and mildly positive for (K) Wilms tumor protein 1. The specimen was also mildly positive for (L) sialyated heart development protein with EGF like domains 1 on the basal surface (magnification for all, ×10).

Figure 4.

Imaging from the start of combination therapy with cisplatin + pemetrexed until after the discontinuation of pemetrexed. (A) Follow-up chest X-ray after four courses of combination therapy with cisplatin + pemetrexed revealed improvement in the right pleural effusion. (B) Follow-up computed tomography after four courses of combination therapy with cisplatin and pemetrexed revealed reduction of the pleural masses diagnosed as malignant pleural mesothelioma (green arrows); (C) however, the nodule in the S10 segment of the right lower lobe appears to have slowly grown (red arrow). At 18 months after chemotherapy initiation, (D) chest X-ray showed that the right pleural effusion remained improved. (E) Computed tomography showed disappearance of the right pleural nodule and right pleural effusion; (F) however, a continuation of the enlargement of nodules nodule in the S10 segment of the right lower lobe was observed (red arrow). (G) ¹⁸F-fluorodeoxyglucose positron emission tomography showed no evidence of distant metastasis of the lung cancer or recurrence of malignant mesothelioma. (H) ¹⁸F-fluorodeoxyglucose positron emission tomography at the same time showed the nodule with abnormal uptake (red arrow).

Figure 5.

Pathological findings of the computed tomography-guided biopsy. Histopathologic examination of the biopsy specimen obtained from the lesion in the S10 segment of the right lower lobe indicates adenocarcinoma. Hematoxylin and eosin staining at a magnification of (A) ×10 and (B) ×40. Periodic acid-Schiff staining at a magnification of (C) ×10 and (D) ×40.