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2013, Volume 29, Number 1, Page(s) 083-086
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DOI: 10.5146/tjpath.2013.01156 |
Metachronous Malignant Mesothelioma and Pulmonary Adenocarcinoma |
İrem Hicran ÖZBUDAK1, Ömer ÖZBUDAK2, Gökhan ARSLAN3, Abdullah ERDOĞAN4, Gülay ÖZBİLİM1 |
1Department of Pathology, Akdeniz University, Faculty of Medicine, ANTALYA, TURKEY
2Department of Pulmonary Medicine, Akdeniz University, Faculty of Medicine, ANTALYA, TURKEY
3Department of Radiology, Akdeniz University, Faculty of Medicine, ANTALYA, TURKEY
4Department of Chest Surgery, Akdeniz University, Faculty of Medicine, ANTALYA, TURKEY |
Keywords: Metachronous neoplasms, Mesothelioma, Lung adenocarcinoma |
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The prevalence of multiple primary malignant neoplasms in a single
patient is reported in a wide variation. The co-existence of malignant
mesothelioma and pulmonary carcinoma is a rare entity. Herein,
we reported a 60-year-old man who was a retired employee and
heavy smoker. He had a suspicious history of asbestos exposure. He
complained of chest pain and computerized tomography revealed a
mass in the lower lobe of left lung. The patient underwent a left lower
lobectomy and was diagnosed as pulmonary adenocarcinoma. During
follow-up two years after surgery, the patient complained of dyspnea
and chest computerized tomography scan revealed right pleural
effusion and diffuse pleural thickening. For the differential diagnosis,
the patient underwent wedge biopsy from the right lower lobe and
was diagnosed as epithelial diffuse malignant mesothelioma. The
development of malignant pleural mesothelioma and lung carcinoma
could be associated with asbestos exposure. However, a history of
asbestos exposure is not required for the diagnosis. The influence
of effective anticancer therapies that improve the survival rates and
increase the population ages could be related to the occurrence of a
second malignancy. |
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The first report of multiple primary malignant neoplasms
in an individual patient was published at the end of the
19 th century. Since then, several papers worldwide have
addressed this issue and the prevalence of multiple primary
malignant neoplasms reported varies from 0.734% to
11.7% 1,2. However, reports from Turkey indicated the
prevalence to be between 0.828% and 1.03% 3,4.
The etiopathogenesis of multiple neoplasms includes
hereditary aspects, the influence of environmental agents,
previous therapies and tumor-producing hormones5-8.
Multiple neoplasms could be defined by when they occur as synchronous and metachronous. The latter is applied for
the neoplasms appearing in a single patient with an interval
more than 6 months9.
The co-existence of malignant mesothelioma and
pulmonary carcinoma is a rare entity and generally such
reports regard single cases and series with a small number
of cases in the English literature10-15. Moreover, this
co-existence has been reported in patients with significant
exposure to asbestos. Herein, we report a rare case of
metachronous malignant mesothelioma and pulmonary
carcinoma with a suspicious history of asbestos exposure. |
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Abstract
Introduction
Case Presentation
Disscussion
References
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A 60-year-old man was admitted to the hospital with a
history of chest pain, dry cough, dyspnea and malaise for
two months. He was a retired employee and heavy smoker
(40 pack years). He had a suspicious history of asbestos
exposure because of the house that he had lived in during
his childhood. On physical examination, diminished breath
sounds were found in the left lung. The chest computerized
tomography (CT) revealed a mass with spicular
projections in the lower lobe of left lung (Figure 1). On
fiberbronchoscopy, no endobronchial lesion was detected.
The patient underwent a left lower lobectomy. The tumor
was firm, grayish-white, 5.5 x 4.5 cm in size and composed
of pleomorphic, atypical epithelial cells forming solid areas. Tumor cells had mucin-positive intracytoplasmic
droplets and the immunohistochemistry showed tumor
cells positive for Cytokeratin 7, Carcinoembryonic antigen
(CEA) and Thyroid transcription factor-1 (TTF-1) (Figure 2A,B). The patient was diagnosed as lung adenocarcinoma
with these findings. He had been treated with cisplatin and
vinorelbine for six months. During follow-up two years
after surgery, the patient complained of dyspnea and chest
CT scan revealed right pleural effusion and diffuse pleural
thickening with irregular and often nodular internal margin
at the right mediastinal pleura (Figure 3). Differential
diagnosis included metastasis of lung adenocarcinoma and
primary tumor of pleura. The patient underwent wedge
biopsy from right lower lobe. Histologically, the malignant
epithelioid cells were arranged in sheets and cords. Diffuse
immunopositivity was detected with Calretinin and
Cytokeratin 5/6 in tumor cells; however, TTF-1 and CEA
were negative (Figure 4A,B). The patient was diagnosed as
epithelial diffuse malignant mesothelioma.
Click Here to Zoom |
Figure 1: The parenchyma window of chest computerized
tomography revealed a tumor with spicular projections in the
lower lobe of left lung. |
Click Here to Zoom |
Figure 2: Adenocarcinoma. (A) Tumor cells were forming solid sheets, (H&E, x20), (B) Tumor cells showed immunopositivity with
TTF-1 (x20). |
Click Here to Zoom |
Figure 3: The mediastinal window of chest computerized
tomography revealed pleural thickening with irregular internal
margin at the right mediastinal pleura. |
Click Here to Zoom |
Figure 4: Malignant mesothelioma. (A) Epithelioid tumor islands were encasing the lung parenchyma (H&E, x2), (B) The tumor was
diffuse positive with Calretinin (x2). |
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Top
Abstract
Introduction
Case Presentation
Disscussion
References
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In the diagnosis of multiple primary malignant neoplasms,
Warren and Gates established three criteria; 1 each of the
tumors must have a definite features of malignancy, 2
each must be distinct, and 3 the probability of one being
a metastasis of the other must be excluded 16. By this
definition, our patient had two different primary malignant
neoplasms. The prevalence widely varies as mentioned
above between the reports worldwide and from Turkey.
This variation may be caused by several factors such as the
criteria to define multiple primaries in a case. Also the case
series whether from clinical or autopsy could change the
prevalence 1-4.
Multiple neoplasms may occur at any age. However, in the
reviewed literature the patients tend to be older than those
with a single tumor4. The reason for increased incidence
of multiple neoplasms by age could be related with long
exposure to environmental causative agents and more
effective antitumor therapies that also prolong patients'
lives and increase the risk of other primary neoplasms.
Our patient was also from the older population and treated
earlier with an aggressive anticancer medication.
Asbestos exposure is a well-recognized risk in the development
of malignant mesothelioma. Epidemiological studies
have demonstrated an increased risk of lung cancer by
asbestos exposure but still the precise pathogenic mechanisms
are unclear. The infrequency of reported co-existence of malignant mesothelioma and lung carcinoma suggests
that the pathogenic mechanisms of asbestos-induced
tumors could be different. It may also be related with the
awareness of concomitant lung carcinoma because of the
extensive mesothelioma.
The evidence of asbestos exposure can be determined from
the patient history as occupation, macroscopic documentation
as pleural plaques, microscopic identification of
asbestos bodies in lung tissue and mineral analysis. In our
patient, although the history was suspicious for asbestos exposure
because of the house that he had been lived in during
his childhood, we could not demonstrate any asbestos
body by light microscopy in the lung tissue and any pleural
plaque in his surgical specimens. It should also be kept in
mind that the consensus statement from the International
Mesothelioma Interest Group that defined the guidelines
for pathologic diagnosis of malignant mesothelioma has
pointed out the uselessness of the presence or absence of
an asbestos history in making a diagnosis of mesothelioma17.
In conclusion, a review of the existing data from the
literature showed that the development of malignant pleural
mesothelioma and lung carcinoma has infrequently been
reported and could be associated with asbestos exposure.
However, the history of asbestos exposure is not required
for the diagnosis. Generally, a patient who developed one
malignancy might be at greater risk of developing a second.
This might be related with the initiating and promoting
factors which probably still exist after occurrence of the
first tumor. The influence of effective anticancer therapies
which improve the survival rates and population ages could
also be related. Further studies are needed to address the potential of cancer patients being at higher risk of multiple
primary tumors and to explain the causative agents. |
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Abstract
Introduction
Case Presentation
Discussion
References
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1) Berge T, Cederqvist L, Schonebeck J. Multiple primary malignant tumours. An autopsy study of a circumscribed population. Acta Pathol Microbiol Scand 1969,76:171-183 [ PubMed ]
2) Haddow AJ, Boyd JF. Multiple primary neoplasms in the Western Hospital Region, Scotland: a survey based on cancer registration data. Scott Med J 1972, 17:143-152 [ PubMed ]
3) Engin K. Cancers in multiple primary sites. Int Surg 1994, 79:33-37 [ PubMed ]
4) Aydiner A, Karadeniz A, Uygun K, Tas S, Tas F, Disci R, Topuz E. Multiple primary neoplasms at a single institution: differences between synchronous and metachronous neoplasms. Am J Clin Oncol 2000, 23:364-370 [ PubMed ]
5) Itil O. Akciger kanserlerinin epidemiyolojisi ve etiolojisi. In:Haydaroglu A (Ed): Akciger kanserleri, tanı ve tedavi. 1st ed., İzmir, Ege Üniversitesi Basımevi, 2000, 15-34
6) Sozzi G, Miozzo M, Pastorino U, Pilotti S, Donghi R, Giarola M, De Gregorio L, Manenti G, Radice P, Minoletti F, Della Porta G, Pierotti MA. Genetic evidence for an independent origin of multiple preneoplastic and neoplastic lung lesions. Cancer Res 1995, 55:135-140 [ PubMed ]
7) Leone G, Mele L, Pulsoni A, Equitani F, Pagano L. The incidence of secondary leukemias. Haematologica 1999, 84:937-945 [ PubMed ]
8) Habal N, Sims C, Bilchik AJ. Gastrointestinal carcinoid tumors and second primary malignancies. J Surg Oncol 2000, 75:310-316 [ PubMed ]
9) Matzkin H, Braf Z. Multiple primary malignant neoplasms in the genitourinary tract: occurrence and etiology. J Urol 1989, 142:1-12 [ PubMed ]
10) Cagle PT, Wessels R, Greenberg SD. Concurrent mesothelioma and adenocarcinoma of the lung in a patient with asbestosis. Mod Pathol 1993, 6:438-441 [ PubMed ]
11) Kishimoto T. A case of triple malignancies (gastric cancer, lung cancer and malignant pleural mesothelioma) after asbestos exposure. Nihon Kokyuki Gakkai Zasshi 2003, 41:304-309 [ PubMed ]
12) Attanoos RL, Thomas DH, Gibbs AR. Synchronous diffuse malignant mesothelioma and carcinomas in asbestos-exposed individuals. Histopathology 2003, 43:387-392 [ PubMed ]
13) Allen TC, Moran C. Synchronous pulmonary carcinoma and pleural diffuse malignant mesothelioma. Arch Pathol Lab Med 2006, 130:721-724 [ PubMed ]
14) Lee AH, Soomro IN. Collision tumour of the pleura composed of small cell carcinoma and malignant mesothelioma. Histopathology 2004, 45:305-306 [ PubMed ]
15) Bianchi C, Bianchi T, Ramani L. Malignant mesothelioma of the pleura and other malignancies in the same patient. Tumori 2007, 93:19-22 [ PubMed ]
16) Warren S, Gates O. Multiple primary malignant tumors:a survey of the literature and a statistical study. Am J Cancer 1932, 16:1358-1114
17) Husain AN, Colby TV, Ordonez NG, Krausz T, Borczuk A, Cagle PT, Chirieac LR, Churg A, Galateau-Salle F, Gibbs AR, Gown AM, Hammar SP, Litzky LA, Roggli VL, Travis WD, Wick MR. Guidelines for pathologic diagnosis of malignant mesothelioma: a consensus statement from the International Mesothelioma Interest Group. Arch Pathol Lab Med 2009, 133:1317-1331 [ PubMed ] |
Top
Abstract
Introduction
Case Presentation
Discussion
References
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