Primary Pericardial Mesothelioma: A Rare but Serious Consideration

Abstract

Primary pericardial mesothelioma (PPM) is an extremely rare malignancy with a very poor prognosis. It poses a diagnostic challenge given its often late and non-specific presentation. This report describes a 74-year-old man who presented with central pleuritic chest pain and mild breathlessness. The patient was febrile and mildly tachycardic with crepitations in the right lung base. Blood tests revealed raised inflammatory markers and chest X-ray showed no acute pathology. Following admission, CT pulmonary angiogram showed a large left-sided mediastinal mass (approximately 110 x 70 x 85 mm) centered on the pericardium. Further post venous phase CT imaging identified possible myocardial invasion alongside suspicious liver nodules. Later, outpatient fluorodeoxyglucose (FDG) positron emission tomography (PET) imaging highlighted further FDG avid pleural and liver lesions. CT-guided biopsy of the pericardial lesion was undertaken, with histology and immunohistochemistry indicating epitheliod-type mesothelioma. A significant malignant pericardial effusion was also identified, which ultimately required pericardial window formation. Immunotherapy was commenced utilizing dual nivolumab and ipilimumab, a novel regime for the treatment of mesothelioma. Palliative radiotherapy to the pericardial lesion will also be performed. Here, we demonstrate the diagnostic challenge of this vanishingly rare condition, which is usually diagnosed upon the development of associated complications. Early recognition gives the best chance of improved mortality, however, diagnosis requires a high index of clinical suspicion alongside prompt investigation, primarily involving cross-sectional imaging.

Unveiling the mystery: a rare case of localized malignant pericardial mesothelioma—case report

“…In summary, localized pericardial thickening and massive pericardial effusions are easily missed and misdiagnosed in patients. At the same time, the positive rate of pleural effusion is low, which cannot be used as a diagnostic criterion of negative PMPM ( 10 , 11 ). For such cases, various laboratory tests and imaging methods need to be improved, and special methods should be adopted for pleural effusion drainage and pathological examination.…”

Primary malignant pericardial mesothelioma with a survival of 2.5 years: a case report

“…Malignant pericardial mesothelioma is clinically rare with a poor prognosis and an average survival time of 6–10 months ( 7 ). There is a lack of effective treatment, and patients are promptly treated with surgery and postoperative adjuvant chemotherapy to improve their quality of life and prolong survival ( 8 , 9 ). The patient reported in this case had a survival of 2.5 years, whereas previous studies of the disease found a mean survival of 6–10 months and a maximum survival of 2 years.…”

PET/CT Showing a Case of Langerhans Cell Histiocytosis Involving the Pleura

“…In our case, LCH involved only the pleura. Mesothelioma, 12 metastasis, 13 lymphoma, 14 nocardiosis, 15 IgG4-related disease, 16 and malignant nerve sheath tumors 17 can involve the pleura and show abnormal FDG uptake on PET/CT. This case indicates that LCH can be a differential diagnosis when we interpret multiple pleural FDG-avid lesions on PET/CT.…”