A 64-year-old male, with no toxic habits, no family history of cancer and no exposure to asbestos in the workplace, who consulted in October 2005 for a constitutional condition with asthenia, anorexia and mild weight loss of 3 months.
She did not take medication regularly.
The physical examination revealed hypoventilation of the lower two thirds of the right hemithorax and a significant right pleural effusion appeared on chest X-ray, with no signs of parenchymal condensation.
No pathological results were found in biochemistry or blood count.
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Bronchoscopy and serial bronchoscopy were performed, but no pathological findings were observed (no lesions suggestive of malignancy).
The characteristics of the pleural fluid (LP), light-yellow, were compatible with an exudate: Glucose 40 mg/dl, LDH (LP)/LDH (serumLP) > 0.6 and proteins > 0.6.
No malignant cells were observed in the cytology.
Right-sided TAC showed diffuse thickening of the right diaphragmatic crura throughout its circumference, also showing involvement of the anterior chest wall, with involvement of the anterior rectus muscle and anterolateral abdominal wall.
Right pleural effusion and minimal ascitic free fluid were also observed.
An ultrasound-guided biopsy of the anterior abdominal wall was then performed, which showed a mesothelial cell proliferation with marked intensity compatible with epithelial mesothelioma subtype.
The tumor cells expressed in the immunohistochemistry CKAE-1-AE3, CK-7 and calretinin (nuclear and cytoplasmic) being negative CK-20 and CEA.
Other types of tumors such as carcinoma, lymphoma, sarcoma or melanoma were ruled out.
A PET-CT was requested, which showed intense hypermetabolism in the peritoneum (SUV max = 13.9 g/ml), at the perihepatic level with extension to the chest wall and malignancy in the left hypochondrium.
There was also a large right pleural effusion associated with atelectasis, both ametabolic.
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Finally, the definitive diagnosis of malignant mesothelioma of peritoneal origin with advanced and unresectable thoracic wall involvement was reached.
Surgery was ruled out because of the extension of the disease, it was decided to start systemic chemotherapy with the cisplatin-pemetrexed regimen.
After three complete cycles, a partial radiological response of the disease was evident.
However, the evolution was torpid, with diarrhea, renal failure and in the context of neutropenia grade 4, secondary to cytologic treatment.
Despite supportive treatment with intravenous fluid therapy and broad-spectrum antibiotics, the patient did not improve, and finally died in March 2006.
