Brain metastases in malignant pleural mesothelioma. Case report and review of the literature

Recent advances in pleural malignant mesothelioma include the sequential use of palliative surgery, perioperative radiation therapy, and systemic chemotherapy. Radical treatments may not only palliate but also improve survival in some patients. The latter may be associated with the appearance of metastases in unusual sites including the central nervous system. In malignant mesothelioma, brain metastases were previously reported in 19 patients at autopsy and in only 1 patient antemortem. We detail the clinical presentation in the second patient with pleural malignant mesothelioma thus far reported to develop brain metastases. The difficulties in diagnosis, the role of immunoperoxidase stains in malignant mesothelioma, excellent tolerance of different modalities of treatment, and a review of the literature of brain metastases in mesothelioma are discussed. Based on our report, the possibility of brain metastases should be investigated by careful clinical examination prior to a radical treatment in patients with progressive refractory mesothelioma.     

Malignant mesothelioma in young adults

Ten cases of malignant mesothelioma presenting in patients 40 years old or younger at diagnosis were reviewed. Seven cases had a documented history of asbestos exposure of which five were household exposures. The median age at first exposure to asbestos was 10 years and the median duration of exposure was 120 months. The median latency period (time between initial asbestos exposure and diagnosis of malignant mesothelioma) was 19 years. The median interval from initial symptoms to definitive diagnosis was 5.5 months. The case history of each patient is presented. A significant delay in diagnosis in this age group compared with an age-unrestricted series is noted. The significance of nonoccupational exposure to asbestos is emphasized as a probable causative factor in the development of malignant mesothelioma. In addition, a possible genetic predisposition is briefly discussed.     

Paratesticular rhabdomyosarcoma in childhood.

The paratesticular region was the primary site in 20 of 289 children (7%) entered on the Intergroup Rhabdomyosarcoma Study. The 20 patients were 1.7- to 19-years-old at diagnosis. Fifteen underwent retroperitoneal node dissection (12) or biopsy (3), and 6/15 (40%) had nodal involvement by tumor. Nineteen of the 20 patients had no gross local or metastatic disease after surgery. All 20 received chemotherapy, and 13 also received radiotherapy. Treatment was effective: 16 of 18 evaluable patients (89%) were free of disease at a median of 23 months from diagnosis (range, 8-43 months). Since the incidence of tumor-involved retroperitoneal nodes is high, a dissection should be performed. If the nodes are free of tumor, retroperitoneal radiotherapy may not be necessary. Reduction of morbidity in patients with paratesticular rhabdomyosarcoma is desirable, because the disease has a good prognosis.     

Herpes zoster in mesothelioma. A case report

Diffuse mesothelioma with a large pleural effusion was diagnosed nine months after the appearance of herpes zoster in the overlying thoracic segment in a patient presenting with chest pain mimicking post-herpetic neuralgia. Clinical implications of such an association are discussed.     

Paratesticular rhabdomyosarcoma: report from the Italian and German Cooperative Group.

PURPOSE: We report the experience of the German-Italian Cooperative Group with 216 pediatric patients with paratesticular rhabdomyosarcoma treated over 20 years. PATIENTS AND METHODS: At diagnosis, 198 patients had localized disease and 18 had distant metastases. Among the nonmetastatic patients, complete tumor resection was performed in 83% of cases. Evaluation of the retroperitoneal lymph nodes changed over the years from routine surgical staging to radiologic assessment. All patients received chemotherapy, which was reduced in intensity and duration for patients with low-risk features in subsequent protocols. Radiotherapy was administered to 10% of patients. RESULTS: Among 72 patients with a negative retroperitoneal computed tomography (CT) scan, surgical assessment detected nodal involvement in only one case. Among 23 patients with enlarged nodes on CT scans, surgery confirmed nodal spread in 65% of patients. No differences in the rate of nodal involvement were observed over the years. With a median follow-up of 110 months, 5-year survival was 85.5% for the series as a whole, 94.6% for patients with localized disease, and 22.2% for metastatic cases. Retroperitoneal nodal recurrence was the major cause of treatment failure. Univariate analysis revealed the prognostic value of tumor invasiveness, size, and resectability, as well as of nodal involvement and age, in patients with localized tumor. CONCLUSION: The outcome for patients with localized paratesticular rhabdomyosarcoma is excellent, despite the reduction in chemotherapy over the years: an alkylating agent-free and anthracycline-free regimen is adequate treatment for low-risk patients. Surgical assessment of the retroperitoneum must be reserved for patients with enlarged nodes on CT scans. Children over 10 years old carry a higher risk of nodal involvement and relapse.     

Cerebral metastases in pleural mesothelioma: Case report and review of the literature

A case of malignant mesothelioma metastatic to the brain is described. A 52-year old woman, with no known exposure to asbestos, presented with a biphasic mesothelioma of the left parietal pleura. Following resection, the thorax was irradiated with 4000 cGy, and all symptoms subsided. Three months later, a left temporal lobe tumor was diagnosed and subsequently resected. Despite neurological improvement, she died 10 days postoperatively from constrictive pericardial disease. The authors have reviewed the 54 reported cases of brain metastases from mesothelioma and have noted that the histologic appearance of brain metastases from mesothelioma may be similar to glioblastoma multiforme. Because brain metastasis from mesothelioma is rare, procedures to clarify the nature of the tumor should be performed.     

The enigma of young age.

Breast cancer in very young patients has traditionally beenconsidered as particularly aggressive and associated with apoor prognosis. The negative prognostic impact of young agehas been substantiated in numerous studies of clinical databases[1–4] including a recent population-based analysis ofpatients with stage I breast cancer: After adjusting for tumorsize, histological grade, estrogen receptor (ER) expression,and year of diagnosis, the age at diagnosis was still a significantpredictor with each year younger than 45 years adding a relative5% to the risk of death from breast cancer [5]. The distinctionbetween young and ‘very young’ premenopausal patientsis fuzzy but most investigators who chose to dichotomize theiranalysis used an age limit of 35–40 years. It appears obvious that age by itself cannot explain the lessfavorable outlook     

Osteomyelitis due to Cryptococcus neoformans in advanced age. Case report and review of literature

In an 84-year-old man cryptococcosis with a pronounced osteomyelitic course (involvement of a rib, two thoracic vertebrae, the sacrum and a femur) was diagnosed histologically post mortem, thus directing attention to cryptococcosis in advanced age. The presumptive chronic course of the Cryptococcus neoformans (Cr. n.) infection in this patient was ascribed to chronic kidney failure, diabetes mellitus and chronic obstructive lung disease. Special reference is made to the mycological and radiological diagnosis of cryptococcosis of the bones as well as to its pathogenesis, therapy and epidemiology.     

Paratesticular desmoplastic small round cell tumor: case report and review of the literature.

Desmoplastic small round cell tumor (DSRCT) is a rare neoplasm mainly affecting young males and typically located in the abdomen. Prognosis is generally very poor. We report a rare case of paratesticular DSRCT in a 17-year-old boy, presenting with an isolated left scrotal mass. The patient had an excellent outcome after complete surgical resection of the tumor and adjuvant multi-agent chemotherapy. DSRCT should be included in the differential diagnosis of small round cell tumors of the paratesticular region in adolescents and young adults. Tumor resection and chemotherapy may be beneficial for these patients. Our experience and a review of the literature suggest that DSRCT located in the paratesticular region may have a better prognosis than its more frequent abdominal counterpart.     

Distinctive clinical characteristics of malignant mesothelioma in young patients

Although considered a disease of the elderly, a subset of patients with mesothelioma are young (<40 years). The goal of this study was to understand their characteristics and outcomes. The Surveillance, Epidemiology, and End Results (SEER) database was used to extract mesothelioma cases (1990-2010). We modeled Kaplan-Meyer survival curves stratified by site of disease, and age of presentation. 2% (207 of 12345) of mesothelioma patients are young. Sex distribution is comparable among the young (51% males, 49% females); males predominated (78%, 22%) in the older cohort. Frequency of pleural and peritoneal mesothelioma are similar in the young (47%, 48% respectively); pleural disease predominated in the old (90%, 9%). Cancer-directed surgeries are more frequent in the young. Regardless of histologic subtype, young patients with pleural (11 vs. 8 months) and peritoneal (not reached vs. 10 months) mesothelioma had significantly improved overall survival. In multivariate analysis, younger age was an independent prognostic factor. Although rare, mesothelioma do occur in the young; their characteristics are distinct from those of older patients. Further studies are needed to understand the interplay between genetic susceptibility and mineral fiber carcinogenesis in the pathogenesis of mesothelioma in the young.     

Case report. Rhinocerebral zygomycosis

A case of rhinocerebral zygomycosis treated with liposomal amphotericin B is described.     

Mesenteric fibromatosis. Case report

Deep fibromatosis is a rare locally aggressive but not metastasizing proliferation. Intra-abdominal fibromatosis (IAF) occurs either in association with Gardner's syndrome or as a sporadic event and presents in most cases differential diagnostic problems with myofibroblastic or fibroblastic tumors, characterized by a more aggressive biological behaviour such as gastrointestinal stromal tumors (GISTs). In absence of loco-regional and/or distant metastasis differential diagnosis may be difficult and represents a topical issue, since it influences treatment choice.We describe the case of a patient with sporadic IAF in which the tumor locally involved the mesentery and presented no loco-regional and distant spread. On histology, some morphological features of the neoplasm were in common with a GIST. Definitive diagnosis was made, postoperatively, on the basis of immunohistochemical findings.     

Malignant mesothelioma presenting as stroke--a case report

A case of a 64-year-old man with metastatic malignant mesothelioma is described in detail. When he presented to us he gave a history suggestive of transient ischaemic attack (TIA) 2 weeks before and 3 days after admission he developed weakness of the left upper limb. Computed tomographic scan of the brain revealed a solitary metastasis in the right cerebrum. A few days later, he developed subcutaneous metastasis in the chin. Malignant mesothelioma is considered to metastasize rarely and to spread locally. We suggest that distant metastasis in malignant mesothelioma is not uncommon and may be considered to behave like other forms of lung cancer. Treatment modalities should be studied in such patients.     

Cerebral metastases in malignant mesothelioma: a case report

A case of a 61-year-old man with metastatic malignant mesothelioma is described. Four months after diagnosis the patient commenced chemotherapy with liposomal doxorubicin as part of an EORTC phase II trial. He developed signs of intracerebral metastases after his fourth cycle of chemotherapy and died shortly after. Malignant mesothelioma is traditionally viewed as a disease that spreads locally but metastasizes rarely. We describe in detail this case and suggest that metastases in this disease are not as uncommon as originally proposed.