Laparoscopic diagnosis of pleural mesothelioma presenting with pseudoachalasia

Abstract

Pseudoachalasia due to pleural mesothelioma is an extremely rare condition. A 70-year-old woman presented with progressive dysphagia for solid and liquids and a mild weight loss. A barium swallow study revealed an esophageal dilatation and a smoothly narrowed esophagogastric junction. An esophageal manometry showed absence of peristalsis. Endoscopy demonstrated an extrinsic stenosis of the distal esophagus with negative biopsies. A marked thickening of the distal esophagus and a right-sided pleural effusion were evident at computed tomography (CT) scan, but cytological examination of the thoracic fluid was negative. Endoscopic ultrasound showed the disappearance of the distal esophageal wall stratification and thickening of the esophageal wall. The patient underwent an explorative laparoscopy. Biopsies of the esophageal muscle were consistent with the diagnosis of epithelioid type pleural mesothelioma. An esophageal stent was placed for palliation of dysphagia. The patient died four months after the diagnosis. This is the first reported case of pleural mesothelioma diagnosed through laparoscopy.

Diffuse Leiomyomatosis of the Esophagus – A Rare Cause of Pediatric Pseudoachalasia.

“…The commonest malignant cause of pseuoachalasia is carcinoma of distal esophagus. Other malignant causes include carcinoma of lung, pancreas, hepatobiliary malignancies, mesothelioma and lymphoma [3,4].…”

“…However, long standing achalasia is a risk factor for carcinoma of esophagus. The mechanism of dysphagia in pseudoachalasia of carcinoma is encasement of the lower esophageal sphincter by tumor / infiltration of the myenteric plexus / para neoplastic neuropathy [4].…”

Duration of symptoms and manometric parameters offer clues to diagnosis of pseudoachalasia

“…Primary or secondary cancer accounts for approximately 70% of cases, with esophageal and gastric cancer being the most common. Other neoplastic processes implicated include leiomyomatosis, pancreatic carcinoma, multiple myeloma, small cell lung cancer, mesothelioma, and breast cancer 3‐11 …”

“…2 While primary achalasia is idiopathic in nature, a number of disorders can manifest similar symptoms and manometric findings, termed pseudoachalasia. 3,4 Various pathophysiologic processes including malignant obstruction at the distal esophagus or cardia; obstruction from tight fundoplication, laparoscopically placed gastric bands, paraesophageal hernia, and paraneoplastic effects of distant malignancy [3][4][5][6][7][8][9][10][11] can contribute to pseudoachalasia. Primary or secondary cancer accounts for approximately 70% of cases, with esophageal and gastric cancer being the most common.…”

“…Other neoplastic processes implicated include leiomyomatosis, pancreatic carcinoma, multiple myeloma, small cell lung cancer, mesothelioma, and breast cancer. [3][4][5][6][7][8][9][10][11] High-resolution manometry (HRM) is performed when esophagogastroduodenoscopy (EGD) or/and barium esophagram is unrevealing in a patient with obstructive esophageal symptoms 12 and has emerged as a technique with higher sensitivity for detection of motor abnormalities compared to conventional manometry. 13,14 Esophageal outflow obstruction, the hallmark finding in achalasia spectrum disorders, can be identified when the integrated relaxation pressure (IRP) is above the upper limit of normal on esophageal HRM, as defined by the Chicago Classification version 3.0.…”