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Elderly woman with sharp shoulder pain

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Chest radiographs are useful, but CT scans are more sensitive

Often, MPM is initially suspected because of unilateral pleural nodularity or thickening with a large, unilateral pleural effusion on a chest radiograph.6 Pleural plaques may also be seen. As the tumor grows, encasing the lung and invading the fissures, it leads to volume loss of the affected side, which can also be identified radiographically.1

Clinical findings of malignant pleural mesothelioma are frequently nonspecific and may masquerade as innocuous shoulder pain.

CT is a more sensitive way to detect pleural and pulmonary parenchymal involvement, as well as invasion of adjacent thoracic structures, including the chest wall, pericardium, diaphragm, and the mediastinal lymph nodes.1

When mesothelioma is suspected because of clinical or radiologic data, experts recommend that cytologic findings from thoracentesis be followed by tissue confirmation from thoracoscopy or CT biopsy.2

Chemotherapy, Yes, but there are many Tx unknowns

The best approach to treatment of MPM remains controversial due to the rarity of the disease and the scarcity of randomized prospective trials. Surgical resection is most often performed when the disease is confined to the pleural space. An extrapleural pneumonectomy is usually performed for stage I disease, when the tumor is limited to one hemithorax, invading the pleura and involving the lung, endothoracic fascia, diaphragm, or pericardium.7

Unfortunately, mesothelioma is highly radioresistant; patients often endure severe toxicity due to large radiation fields. Chemotherapy, either as single agents or in combination, can be administered systemically or directly into the pleural space. Combination chemotherapy using cisplatin and pemetrexed is currently the standard of care, based upon a phase III trial that demonstrated prolonged overall survival with the combination compared to treatment with cisplatin alone (12.1 months vs 9.3 months).8

Combination chemotherapy, using cisplatin and pemetrexed, is currently the standard of care for malignant pleural mesothelioma.

Other agents used to treat MPM. Five other chemotherapy agents are also used in the treatment of MPM. Used individually, the maximum response rates to these agents are as follows: methotrexate (37%), mitomycin (21%), doxorubicin (16%), cyclophosphamide (13%), and carboplatin (11%).7

Our patient. The rest of our patient’s hospital course was uncomplicated. She was not a surgical candidate because she had such extensive tumor involvement. She was discharged with a referral to an outpatient oncology clinic. Despite 2 cycles of carboplatin and pemetrexed, and palliative radiation therapy to the right upper thoracic mass, the disease progressed with worsening right upper extremity pain and neurologic deficits.

CORRESPONDENCE
Mark Guelfguat, DO, Jacobi Medical Center, Albert Einstein College of Medicine, 1400 S Pelham Parkway, Building 1, Room 4N15, Bronx, NY 10461; mguelfguat@gmail.com.

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