A-26-year-old male attended the emergency department with intense pain, of a right-sided supraclavicular lump, with signs of visible inflammation. The history of the presented lymph node revealed that the swollenness was initially presented three months ago. In spite of the gradual enlargement, the patient did not seek any medical advice or treatment. On chest palpation, there was edema, redness, and lymphatic obstruction of the right tracheal position, pectoralis, shoulder, and humerus. There was no abnormality of chest expansion and symptoms of fever, night sweats, and infection. The patient complained of fatigue that gradually escalated during the past 3 weeks, but without any weight loss. On lung percussion, the right side was equal to the left and resonant. On lung auscultation, there were vesicular breath sounds and there was no reduced air entry, no crackles, no wheeze, and no crepitating or rub. Clinical examination of the abdomen revealed ascites, and abdominal U/S confirmed peritoneum effusion (exudate). There were no other pathologic findings on cardiovascular and neurological examination. Past medical history did not reveal any previous medical problems or operations. The patient was on no regular medication. Social history excluded smoking, illegal drug, and alcohol abuse. The chest X-ray showed no pathology. On further questioning, the patient mentioned that his school building was constructed with asbestos-containing materials and that it was recently demolished by the local prefecture authorities. This exposure was the only asbestos exposure he had during his life. During hospitalization, he developed an acute right-sided chest pain. His ECG was normal; however, the CT scan of the trachea demonstrated an enlarged supraclavicular node (), and on the CT scan of the thorax (), nodes between the vessels of the upper mediastinum were demonstrated. In addition, small pleural effusion and an epiphrenic node on the right were observed (). Further evaluation of the patient was done to evaluate the local extension of the lesion beginning from the right supraclavicular node to the right pectoralis with MRI. The MRI of the upper thorax revealed that the lesion had irregular contour, involving the major pectoralis muscle (). At that time, the possibility of mesothelioma was considered, as there were no other clinical or laboratory findings supporting any specific diagnoses. Diffuse malignant mesothelioma arises from the mesothelium. It can occur in any of the body cavities covered by mesothelium, most frequently in the pleura or peritoneum, but also in the pericardium or tunica vaginalis testis [15
]. Also a similar case with malignant mesothelioma that infiltrated the pectoralis has recently been published [16
Axial enhanced CT-image of paratracheal right-sided mass and pleural effusion.
Axial enhanced CT-image of the lower part of the chest (mediastinal window) shows small pleural effusion and an epiphrenic node at the right. Ascites and thickness of the right crus are also noticed.
Figure 4 Axial stir (short-tau-invesion-recovery) MR image of the upper thorax demonstrates a lesion located in the right part of the anterior thoracic wall and shows increased inhomogeneous signal intensity. The lesion has irregular contour, involving the major (more ...)
Although thoracoscopy is usually the routine procedure to obtain a pleural biopsy, an alternative method of biopsing the enlarged supraclavicular lymph node () was preferred to confirm the diagnosis of mesothelioma [13
]. The result of the biopsy was positive for malignant metastatic mesothelioma. A second biopsy was performed and the sample was sent to another pathology department, in order to exclude any possible error. The result of the second biopsy was also positive for metastatic malignant mesothelioma. Immunohistochemistry method was positive for the following staining profile: AE1/AE3, WT-1, and calretinin, D2-40 and negative for CEAp, TTF-1. The patient was stage IV according to the International Mesothelioma Group (IMIG) [17
]. Unfortunately none of the pathology laboratories were able to define the subtype of the mesothelioma (epithelial, sarcomatoid, or mixed), which is a very important prognostic factor. The patient refused to undergo another diagnostic biopsy, since it was explained to him the extent of the disease and the cost effect of another biopsy, since it would not change his therapeutic treatment approach. The staging was done with CT scan of the thorax, abdomen, brain, and bone scintiscan. Due to the initial extent of the disease (supraclavicular lymph node), it was decided not to perform further diagnostic evaluation (e.g., PET scan).
The treatment of malignant pleural mesothelioma (MPM) has evolved in the past 20 years. Treatment selection was based on tumor stage and patient's overall medical condition. Two randomized trials have now established the combination of cisplatin and an antifolate pemetrexed or raltitrexed as the standard in the systemic therapy for mesothelioma [18
]. In a published study on those who actually received chemotherapy, immediate treatment was associated with a significantly longer time to symptomatic progression and a trend to improved overall survival: 66% at 1 year compared to the “delayed” patients (36%), whose quality of life was less well maintained. Whether the true improvement in median survival with chemotherapy will be in the observed magnitude of 3-4 months is doubtful. As is the case in advanced NSCLC, the estimated median improvement in a general mesothelioma population eligible for platinum-based chemotherapy will probably average 8–10 weeks [20
]. Although, strictly speaking, head-to-head comparisons between cisplatin/pemetrexed, cisplatin/raltitrexed, MVP, or vinorelbine need to be conducted, it is foreseeable that, also in analogy with NSCLC, none of these regimens will prove to be superior and that criteria other than outcome will become decisive: toxicity, compliance, and ease of administration. We chose to treat the patient with carboplatin, gemcitabine and, pemetrexed as reported in other studies, due to the excellent performance status but also for psychological reasons to encourage the young patient. The multimodality treatment protocols have achieved a median survival of 19 to 46 months depending on the stage, histology, and completeness of the surgical resection [21
]. In a certain subgroup of patients with epithelial histology, no lymph node involvement, and complete surgical resection, the results were even more favorable with occasional long-term survival [21
]. During the evolution of the treatment of MPM, successful local control of the disease with acceptable morbidity and mortality has been achieved through extra pleural pneumonectomy (EPP) and adjuvant high-dose hemithoracic irradiation [22
]. The feasibility of high-dose hemi thoracic irradiation following EPP was investigated in a phase II trial from Memorial Sloan Kettering Cancer center with local control rates over 90% [22
]. In a similar study from MD Anderson Cancer center, despite successful local control, distant recurrence, especially in the abdomen, was a major problem in long term [27
]. The patient received six cycles of chemotherapy with initial response. A decrease in mediastinum and supraclavicular lymph nodes was observed. The inflammation and lymphatic obstruction on the right supraclavicular area was yielded. At his last followup, 2 months after his last chemotherapy session, the patient was referred to our department with extensive ascites, despite the stable disease on the thorax. It was decided to initiate chemotherapy with carboplatin AUC 5.5 and docetaxel 100
, not only based on our center's experience and clinical practice, but also based on previous published trials [28