Malignant mesothelioma with unexpected contralateral mediastinal shift: a case report
© Myerson et al; licensee BioMed Central Ltd. 2008
Received: 05 October 2007
Accepted: 28 April 2008
Published: 28 April 2008
Contralateral mediastinal shift due to pleural mesothelioma tissue, rather than a pleural effusion, is an unusual clinical feature of mesothelioma.
A 63-year-old woman with a past history of treated invasive ductal carcinoma of the breast presented with breathlessness and chest pain. Her chest radiograph revealed contralateral mediastinal shift and drainage of over 3 litres of pleural fluid relieved her symptoms. She underwent further investigations which revealed pleural mesothelioma, rather than the expected metastatic breast cancer. When she represented with breathlessness a few months later, a chest radiograph again demonstrated contralateral mediastinal shift. A thoracic ultrasound on this occasion revealed only a small loculated pleural effusion and, unexpectedly, a large volume of malignant tissue, thereby explaining the chest radiograph appearances.
This case illustrates mediastinal shift away from the affected side which was caused by mesothelioma tissue itself, rather than by a pleural effusion which is the more usual cause of contralateral mediastinal shift in mesothelioma.
In malignant mesothelioma, the hemithorax affected is usually contracted and imaging typically shows ipsilateral volume loss, and sometimes, mediastinal shift towards the affected side. Pleural fluid associated with malignant mesothelioma is a very common presentation of this disease and may occasionally cause mediastinal shift if the effusion is large enough. However, mediastinal shift due to the mesothelioma tissue itself rather than associated fluid, is uncommon and there is only one previously reported case series of four patients 20 years ago . We present the case of a 63-year-old lady with malignant mesothelioma of the left hemithorax.
A pleural biopsy performed via a Video Assisted Thoracoscopic Surgery (VATS) procedure revealed a new primary malignant mesothelioma rather than the expected secondary spread from her breast carcinoma.
Following pleural drainage, she received exit site radiotherapy. She subsequently became more short of breath and a chest radiograph indicated that there was persistent mediastinal shift.
This case illustrates an unusual clinical picture of mesothelioma. We believe it is a useful case to bring to other physicians' attention, as whilst the chest radiograph suggested a large pleural effusion, the CT scan and ultrasound showed this not to be the case. In this situation, repeated attempted pleural drainage would not help the patient's symptoms and may cause unnecessary distress. It shows the effects seen in a patient with mesothelioma with a large burden and volume of disease.
The patient is now deceased. Written informed consent was obtained from the patient's next of kin for publication of the report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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