- Email: [email protected]
Pleural Mesothelioma in Patient with Pulmonary Tuberculosis*
Pleural Mesothelioma
In
Patient with Pulmonary Tuberculosis* Report of a Case
DROS
J.
MARTINIS, M.D. AND VERA R. RADOVIC, M.D.
Belgrade, Yugoslavia
Radiologic studies show diffuse opacity. Loss of weight is associated with pain and dyspnea; later signs of media<;tinal compression appear. Evolution is fast from one month to one and one-half years. Those without exudate evolve more slowly. Diagnosis is difficult, sometimes due to the round shape of shadows of tumors on roentgenogram<;, suggesting hydatid cyst of lungs or liver. Explorative thoracotomy and biopsy determines the diagnosis. According to the available literature, treatment has been symptomatic and consists of repeated aspirations of fluid. In some cases roentgen and isotope therapy have been employed.
I:-ITRODUCTION
1
:-1
1899,
LEPI7': PlJBLISHED
HIS REPORT
on primary pleural cancer. Later, a great deal of research was published on this subject in North :\merica and other countries. Primary pleural cancer is pre~ented anatomicopathologically in two different types: as cancer of covering cells called endothelioma, and sarcoma which is uncommon. Pleural mesothelioma occurs more frequently in men than in women. It usually appears between 40 to 60 years of age. The right pleura is more often affected than the left. These cancers could be clinically divided in two groups, one with effusion and the other without exudate. In the type with effusion, the on~et is usuatty insidious followed by pain in the chest and progressive dvpsnea; coughing is inconstant without expectorations. The involved hemithorax is prominent and with aspiration hemorrhagic exudate is obtained.
C,\SE REPORT
A man, aged 53 years. was referred to the town hospital from the antituberculosis outpatient service on January 5, 1962, with diagnosis of active. moderately advanced pulmonary tuberculosis. On admission he had no history of previous illness. but alcoholism. He had believed his coughing for 30 ypars was due to smoking. Two years ago he began to expectorate purulentgreenish sputum. Examination revealed pulmonary tuberculosis in January. 1961. He was treated at 0111' hosp:tal from February 24, 1961 until November 21, 1961. On discharge the diagnosis was active. moderately advanced pulmonary tuberculosis; myocarditis. chronic alcoholism. At home he took streptomycin. isoniazid and para-aminosalicylic acid. At the end of December, 1961, he developed temperature elevation and cough so he was re-admitted to the hospital with no appetite. Sputum contained acid-fact bacilli. Repeated hemograms showed increasing leukocytosis up to 19,000 per mm 3 • He expectorated mucopurulent sputum. He was constantly febrile to 38° C. and had dypsnea. He had attacks of diarrhea. There was pain in his wrist and shoulder joints. On lifting his left arm, he experienced paresthesia. There was slight edema of arms and legs. He could not press his fingers of the left-hand into a fist. There was a systolic murmur at ictus. The sputum was negative for
·From the People's Republic of Serbia Tuberculosis Institute; Director, Prof. Dr. Milic Grujic.
FIGURE I: Bilateral tuberculous lesions with cavity in the left upper lobe. Sputum smear positive for tubercle bacilli.
568
Volume 47. No. May 196'
PLEURAL MESOTHELIOMA
elastic fibers and malignant cells. It contained isolated bacilli which were resistant to classic antimicrobial drugs. During March. enlarged supraclavicular lymph nodes were discovered which were matted together. He hegan to expectorate bloody sputum. After seven days enlarged lymph nodes appeared bilaterally in the axillary and inguinal regions. The left hemithorax was very prominent. His condition grew worse. On April 12, he left the hospital against doctor's advice, as he had refused hiopsy of lymph nodes. After ten days, he was re-admitted to our institute as an urgent case because of hemoptysis. On admission he was in bad condition with weak voice, dysphonia, cachetic and adynamic. Enlarged lymph nodes were present, especially on the left side of his neck. Over and under the clavicle a finn semicircular prominence was observed, which extended from the sternocleidomastoid muscle to the trapezius which was painful on palpitation. There were Innph nodes in each axilla. On the posterior edge of the left axilla there was a pack of lymph nodes, which
2 (upper): The tumor shadow whi h ext nds up to two-thirds of the left hemithorax with di pia cd mediastinum to th contral teral id. FlO RE 3 (lower): Tomogram at 9 em. level showing tumor mas .
56 9
extended to the back. In the inguinal region on the internal sides of both thighs the enlarged painful lymph nodes were palpated. The left hand was weak. The left hemithorax was promi. nent and the thoracic expansion was not full and equal. Clinical examination of the heart discovered a slight systolic murmur at the ictus. The blood pressure was 120/70 on the left side and 150/90 on the right side. The pulse was softer on the left than on the right side. There was tenderness over the right upper quadrant of the ahdomen. Liver was enlarged and tender on palpitation, but the spleen could not he felt. Roentgenographic findings on routine film: On the left side there was a cavernous lesion whi('h proved to he tuberculous. Sputum smears revealed acid-fast bacilli. The parietal and visceral pleurae were free. There was no pleural effusion. Th<'l"e were no radiologic signs of involvement of ribs or verterbrae. Six months later the trachea and its main branches were extremely displaced to the right. On the left side, there was a homogenous semicircular shadow sharply delineated from the surrounding tissue, with convexity downward. In the apex of the right lung there was a density which represented a tuberculous lesion. (Figs. 2 and 3). Laboratory studies: A hepatogram was with· in normal limits. A hemogram showed erythrocytes 3,200,000 per mm s; hemoglobin 40 per cent; in 0.7. Leukocyte count 41,500 per mm'; granulocytes 84 per cent; lymphocytes 10 per cent; monocytes I per cent. Erythrocyte sedi· mentation rate 90/130 (Westergren). Urinalysis was normal. Temperature 37.8° C. After five days the leukocyte count was 63,500; granulocytes 97 per cent; lymphocytes I per cent; mono· cytes I per cent. Aspiration of a lymph node was performed and malignant cells were found. (Fig. 4). On April 26, the bone marrow was normal. On the 16th day after admission, the patient died in extreme cachexia.
FlO RE
FIGl."RE 4: Typical malignant cells from which one is in mitosis, in the smear of material obtained by aspiration of a left supraclavicular lymph gland.
57°
Diseases of the Chest
MARTINIS AND RADOVIC
Pathologic report (postmortem examination was performed on May 10, 1962): Mesothelioma of visceral and parietal pleurae at the apex of the left lung with massive multiple lymph node metastasis. Fibrocaseous cavitary tuberculosis in apex of right lung. The histologic diagnosis was: mesothelioma of the pleurae. DISCUSSION
The regressive changes of cancer which gave a radiologic appearance of cavitation was thought to be due to tuberculosis since at that time sputum smears and cultures revealed acid-fast bacilli. The course of the disease and the appearance of adenopathies suggested the malignant nature of disease. Malignant cells were looked for in the sputum many times, but were not found, and biopsy was refused. Hemoptysis which appeared at the end of his life and finding malignant cells on aspiration of peripheral nodes suggested the possibility of cancer of the bronchus with metastasis. :\bsence of signs of cervical sympathicus nerve and involvement of ribs, excluded Pancoast's tumor, although there were neurologic and vascular compression signs of the soft tissue of the upper thorax aperture. Before the sternal puncture, high leukocytosis with peripherical adenopathy suggested leukosis. The leukocytosis can be explained as a reaction to metastic malignant diseases in the bone marrow.
With this thinking necropsy was done under suspicion of cancer of the bronchus associated with tuberculosis. We didn't think about the existence of mesothelioma, because the absence of pleural effusion and the existing chronic pulmonary tuberculosis suggested such reasoning. The experience from necropsy warned us to think of the pleura as the origin of malignant proliferation in the differential diagnosis of thoracic diseases. REFERENCES EHRESHAFT,
J.
L., SENSENIG,
D. M.
AND LAW-
RESCE, M. S.: "Mesotheliomas of the Pleura," ]. Thor. Surg., 40: 393, 1960. ~ EISESSTADT, H. B.: "Malignant Mesothelioma of the Pleura," Dis. Chest, 30:549, 1956. 3 WOLCOTT, M. W., SHAVER, W. A., WALKUP, H. E. A~D PEASLEY. E. D.: "Mesothelioma of the Pleura," Dis. Chest, 36: 119. 1959. 4 LEE, B. H.: "Diagnostic des Tumeurs Pleurales Primitives ou Soudisant Telles." La Semaine des Hopitaux, Paris, 38: 1069, 1962. 5 CLAY, A.: "Apropos du Diagnostic Anatomique de Tumeur Primitif de la Plevre," Lille M ed., 6 : 372, 1961. 6 GALY, P.: "Le Diagnostic des Tumeurs Pleurales Primitives ou Soi-disant Telles," ]. M ed. de Bordeaux, 138: 1261, 1961. 7 PARIENTE, R.: "Les Tumeurs Primitives de la Plevre," Le Semaine des H opitaux, Paris, 30: 1233, 1954. 8 THIBIAULT: "Les Tumeurs Primitives de la Plevre," Presse M ed., 68: 1395, 1960. For reprints, please write Dr. Radovic, Tuberculosis Institute, 21 Ognjena Price Street, Belgrade, Yugoslavia.
FETAL HYDROTHORAX Two additional cases of hydrothorax of the newborn are reported. with one infant surviving. The etiology remains obscure. but may be related to Incomplete development of the lymphatics. Trauma wi th secondary rupture of the thoracic duct is also
a definite consideration. The radiographic appearance is similar to any effusion and differentiation from atelectasis is discussed. BORNHURST.
R. A.
AND CARSKY,
E. W.: "Fetal Hydrotho-
rax," Radiology, 83 :476, 1964.
PARGYLINE IN HYPERTENSIVE PATIENTS Pargyllne exerts its antihypertensive effect via a predominant reduction In peripheral vascular resistance. whereas cardiac output is not altered significantly. The effect on renal blood flow is inconsistent. but a significant reduction in glomerular filtration rate does occur. Therefore. the drug should be used with appropriate caution in patients with significant
impairment of renal function. The hemodynamic response observed with pargyline is similar to that obtained with other monoamine oxidase Inhibitors. G., NOVACK, P., RAMIREZ, 0., BREST, A. N. AND H.: "Hemodynamic Effects of Pargyline in Hypertensive Patients," Circulation, 30:830, 1964.
ONESTI,
MOYER. ].
In
Patient with Pulmonary Tuberculosis* Report of a Case
DROS
J.
MARTINIS, M.D. AND VERA R. RADOVIC, M.D.
Belgrade, Yugoslavia
Radiologic studies show diffuse opacity. Loss of weight is associated with pain and dyspnea; later signs of media<;tinal compression appear. Evolution is fast from one month to one and one-half years. Those without exudate evolve more slowly. Diagnosis is difficult, sometimes due to the round shape of shadows of tumors on roentgenogram<;, suggesting hydatid cyst of lungs or liver. Explorative thoracotomy and biopsy determines the diagnosis. According to the available literature, treatment has been symptomatic and consists of repeated aspirations of fluid. In some cases roentgen and isotope therapy have been employed.
I:-ITRODUCTION
1
:-1
1899,
LEPI7': PlJBLISHED
HIS REPORT
on primary pleural cancer. Later, a great deal of research was published on this subject in North :\merica and other countries. Primary pleural cancer is pre~ented anatomicopathologically in two different types: as cancer of covering cells called endothelioma, and sarcoma which is uncommon. Pleural mesothelioma occurs more frequently in men than in women. It usually appears between 40 to 60 years of age. The right pleura is more often affected than the left. These cancers could be clinically divided in two groups, one with effusion and the other without exudate. In the type with effusion, the on~et is usuatty insidious followed by pain in the chest and progressive dvpsnea; coughing is inconstant without expectorations. The involved hemithorax is prominent and with aspiration hemorrhagic exudate is obtained.
C,\SE REPORT
A man, aged 53 years. was referred to the town hospital from the antituberculosis outpatient service on January 5, 1962, with diagnosis of active. moderately advanced pulmonary tuberculosis. On admission he had no history of previous illness. but alcoholism. He had believed his coughing for 30 ypars was due to smoking. Two years ago he began to expectorate purulentgreenish sputum. Examination revealed pulmonary tuberculosis in January. 1961. He was treated at 0111' hosp:tal from February 24, 1961 until November 21, 1961. On discharge the diagnosis was active. moderately advanced pulmonary tuberculosis; myocarditis. chronic alcoholism. At home he took streptomycin. isoniazid and para-aminosalicylic acid. At the end of December, 1961, he developed temperature elevation and cough so he was re-admitted to the hospital with no appetite. Sputum contained acid-fact bacilli. Repeated hemograms showed increasing leukocytosis up to 19,000 per mm 3 • He expectorated mucopurulent sputum. He was constantly febrile to 38° C. and had dypsnea. He had attacks of diarrhea. There was pain in his wrist and shoulder joints. On lifting his left arm, he experienced paresthesia. There was slight edema of arms and legs. He could not press his fingers of the left-hand into a fist. There was a systolic murmur at ictus. The sputum was negative for
·From the People's Republic of Serbia Tuberculosis Institute; Director, Prof. Dr. Milic Grujic.
FIGURE I: Bilateral tuberculous lesions with cavity in the left upper lobe. Sputum smear positive for tubercle bacilli.
568
Volume 47. No. May 196'
PLEURAL MESOTHELIOMA
elastic fibers and malignant cells. It contained isolated bacilli which were resistant to classic antimicrobial drugs. During March. enlarged supraclavicular lymph nodes were discovered which were matted together. He hegan to expectorate bloody sputum. After seven days enlarged lymph nodes appeared bilaterally in the axillary and inguinal regions. The left hemithorax was very prominent. His condition grew worse. On April 12, he left the hospital against doctor's advice, as he had refused hiopsy of lymph nodes. After ten days, he was re-admitted to our institute as an urgent case because of hemoptysis. On admission he was in bad condition with weak voice, dysphonia, cachetic and adynamic. Enlarged lymph nodes were present, especially on the left side of his neck. Over and under the clavicle a finn semicircular prominence was observed, which extended from the sternocleidomastoid muscle to the trapezius which was painful on palpitation. There were Innph nodes in each axilla. On the posterior edge of the left axilla there was a pack of lymph nodes, which
2 (upper): The tumor shadow whi h ext nds up to two-thirds of the left hemithorax with di pia cd mediastinum to th contral teral id. FlO RE 3 (lower): Tomogram at 9 em. level showing tumor mas .
56 9
extended to the back. In the inguinal region on the internal sides of both thighs the enlarged painful lymph nodes were palpated. The left hand was weak. The left hemithorax was promi. nent and the thoracic expansion was not full and equal. Clinical examination of the heart discovered a slight systolic murmur at the ictus. The blood pressure was 120/70 on the left side and 150/90 on the right side. The pulse was softer on the left than on the right side. There was tenderness over the right upper quadrant of the ahdomen. Liver was enlarged and tender on palpitation, but the spleen could not he felt. Roentgenographic findings on routine film: On the left side there was a cavernous lesion whi('h proved to he tuberculous. Sputum smears revealed acid-fast bacilli. The parietal and visceral pleurae were free. There was no pleural effusion. Th<'l"e were no radiologic signs of involvement of ribs or verterbrae. Six months later the trachea and its main branches were extremely displaced to the right. On the left side, there was a homogenous semicircular shadow sharply delineated from the surrounding tissue, with convexity downward. In the apex of the right lung there was a density which represented a tuberculous lesion. (Figs. 2 and 3). Laboratory studies: A hepatogram was with· in normal limits. A hemogram showed erythrocytes 3,200,000 per mm s; hemoglobin 40 per cent; in 0.7. Leukocyte count 41,500 per mm'; granulocytes 84 per cent; lymphocytes 10 per cent; monocytes I per cent. Erythrocyte sedi· mentation rate 90/130 (Westergren). Urinalysis was normal. Temperature 37.8° C. After five days the leukocyte count was 63,500; granulocytes 97 per cent; lymphocytes I per cent; mono· cytes I per cent. Aspiration of a lymph node was performed and malignant cells were found. (Fig. 4). On April 26, the bone marrow was normal. On the 16th day after admission, the patient died in extreme cachexia.
FlO RE
FIGl."RE 4: Typical malignant cells from which one is in mitosis, in the smear of material obtained by aspiration of a left supraclavicular lymph gland.
57°
Diseases of the Chest
MARTINIS AND RADOVIC
Pathologic report (postmortem examination was performed on May 10, 1962): Mesothelioma of visceral and parietal pleurae at the apex of the left lung with massive multiple lymph node metastasis. Fibrocaseous cavitary tuberculosis in apex of right lung. The histologic diagnosis was: mesothelioma of the pleurae. DISCUSSION
The regressive changes of cancer which gave a radiologic appearance of cavitation was thought to be due to tuberculosis since at that time sputum smears and cultures revealed acid-fast bacilli. The course of the disease and the appearance of adenopathies suggested the malignant nature of disease. Malignant cells were looked for in the sputum many times, but were not found, and biopsy was refused. Hemoptysis which appeared at the end of his life and finding malignant cells on aspiration of peripheral nodes suggested the possibility of cancer of the bronchus with metastasis. :\bsence of signs of cervical sympathicus nerve and involvement of ribs, excluded Pancoast's tumor, although there were neurologic and vascular compression signs of the soft tissue of the upper thorax aperture. Before the sternal puncture, high leukocytosis with peripherical adenopathy suggested leukosis. The leukocytosis can be explained as a reaction to metastic malignant diseases in the bone marrow.
With this thinking necropsy was done under suspicion of cancer of the bronchus associated with tuberculosis. We didn't think about the existence of mesothelioma, because the absence of pleural effusion and the existing chronic pulmonary tuberculosis suggested such reasoning. The experience from necropsy warned us to think of the pleura as the origin of malignant proliferation in the differential diagnosis of thoracic diseases. REFERENCES EHRESHAFT,
J.
L., SENSENIG,
D. M.
AND LAW-
RESCE, M. S.: "Mesotheliomas of the Pleura," ]. Thor. Surg., 40: 393, 1960. ~ EISESSTADT, H. B.: "Malignant Mesothelioma of the Pleura," Dis. Chest, 30:549, 1956. 3 WOLCOTT, M. W., SHAVER, W. A., WALKUP, H. E. A~D PEASLEY. E. D.: "Mesothelioma of the Pleura," Dis. Chest, 36: 119. 1959. 4 LEE, B. H.: "Diagnostic des Tumeurs Pleurales Primitives ou Soudisant Telles." La Semaine des Hopitaux, Paris, 38: 1069, 1962. 5 CLAY, A.: "Apropos du Diagnostic Anatomique de Tumeur Primitif de la Plevre," Lille M ed., 6 : 372, 1961. 6 GALY, P.: "Le Diagnostic des Tumeurs Pleurales Primitives ou Soi-disant Telles," ]. M ed. de Bordeaux, 138: 1261, 1961. 7 PARIENTE, R.: "Les Tumeurs Primitives de la Plevre," Le Semaine des H opitaux, Paris, 30: 1233, 1954. 8 THIBIAULT: "Les Tumeurs Primitives de la Plevre," Presse M ed., 68: 1395, 1960. For reprints, please write Dr. Radovic, Tuberculosis Institute, 21 Ognjena Price Street, Belgrade, Yugoslavia.
FETAL HYDROTHORAX Two additional cases of hydrothorax of the newborn are reported. with one infant surviving. The etiology remains obscure. but may be related to Incomplete development of the lymphatics. Trauma wi th secondary rupture of the thoracic duct is also
a definite consideration. The radiographic appearance is similar to any effusion and differentiation from atelectasis is discussed. BORNHURST.
R. A.
AND CARSKY,
E. W.: "Fetal Hydrotho-
rax," Radiology, 83 :476, 1964.
PARGYLINE IN HYPERTENSIVE PATIENTS Pargyllne exerts its antihypertensive effect via a predominant reduction In peripheral vascular resistance. whereas cardiac output is not altered significantly. The effect on renal blood flow is inconsistent. but a significant reduction in glomerular filtration rate does occur. Therefore. the drug should be used with appropriate caution in patients with significant
impairment of renal function. The hemodynamic response observed with pargyline is similar to that obtained with other monoamine oxidase Inhibitors. G., NOVACK, P., RAMIREZ, 0., BREST, A. N. AND H.: "Hemodynamic Effects of Pargyline in Hypertensive Patients," Circulation, 30:830, 1964.
ONESTI,
MOYER. ].