ISSN: 2584-0355

DOI: doi.org/10.51219/MCCRJ/Ifeanyichukwu-Dupe-Nwanji/13

Medical & Clinical Case Reports Journal

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Vol: 1 & Iss: 2 Case Report

Rare Presentation of Pleural Mesothelioma with Associated Dysphagia in an Elderly

Female Cement Trader and the Resultant Diagnostic Challenges: A Case Report
Ifeanyichukwu Dupe Nwanji1*, Omolade Oluwafadekemi Adegoke1 and Babatope Lanre Awosusi2
1
Department of Pathology, University College Hospital Ibadan, Nigeria
2
Department of Histopathology, King Khaled Hospital, Almajma’ah, Saudi Arabia

Citation: Nwanji ID, Adegoke OO, Awosusi BL. Rare Presentation of Pleural Mesothelioma with Associated Dysphagia in an
Elderly Female Cement Trader and the Resultant Diagnostic Challenges: A Case Report. Medi Clin Case Rep J 2023;1(2):43-46.
DOI: doi.org/10.51219/MCCRJ/Ifeanyichukwu-Dupe-Nwanji/13
Received: 31 August, 2023; Accepted: 04 September, 2023; Published: 07 September, 2023
*Corresponding author: Babatope Lanre Awosusi, Department of Histopathology, King Khaled Hospital, 2397, Bin-Abdulmutalib
street, Aljamiyin District, Almajma’ah 15365, Saudi Arabia, Mobile Number: +966554537950, Email: Awosusilanre2@gmail.com

Copyright: © 2023 Nwanji, ID., et al., This is an open-access article distributed under the terms of the Creative Commons
Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author
and source are credited.

ABSTRACT
Mesotheliomas are rare mesenchymal tumours that arise from the neoplastic proliferation of mesothelial cells lining various
body cavities. Dysphagia is a rare complication of advanced mesothelioma usually occurring as a result of tumour compression
or direct invasion of the oesophagus. Here we describe the case of an elderly female cement trader who presented on account
of complaints of difficulty in swallowing of three months duration initially to solid foods and later to liquids. Chest X-Ray
done showed a homogenous opacity in the left lower lung zone with obliteration of the left costophrenic angle. Computed
tomography scan revealed thickened left pleura with reduced left lung volume. Upper gastrointestinal endoscopy revealed a
vague lower oesophageal stricture suggestive of metastatic cancer from a lung primary. Patient had a gastrostomy on account
of severe dysphagia. Her clinical condition deteriorated during the third week of hospital admission. Despite interventions and
intensive care admission, she eventually succumbed to her illness and was certified dead after 25 days of hospital admission. At
autopsy, there was a predominantly left-sided pleural-based mass with irregular thickening of the pleura maximal at the costo-
diaphragmatic region with nodular involvement of the pericardium. Even though the oesophageal lumen was free of tumour
along its length, the closely related aorta was fixed to the vertebral bones by tumour causing a mass effect. A conclusive diagnosis
of epithelioid mesothelioma of the left pleura was made based on the gross and microscopic features of this tumour. This case
suggests that in addition to recognized risks among construction workers exposed to asbestos, cement sellers/traders may also
constitute an epidemiologic risk group for developing pleural mesotheliomas. Large-scale population based prospective studies
may be needed to further explore this risk.
Keywords: Pleural mesothelioma; Dysphagia; Cement trader

Introduction development of mesothelioma ranges from 20 years to more than

40 years4. Dysphagia is a rare, but recognised complication of
Mesotheliomas are rare mesenchymal tumours that arise from
the neoplastic proliferation of mesothelial cells lining various advanced mesothelioma usually occurring as a result of tumour
body cavities including the pleura, pericardium, peritoneum, compression or direct invasion of the oesophagus5.
and the tunica vaginalis1. The majority of mesotheliomas arise
in the pleural cavity with a significant male predominance2. This case report highlights the unusual and rare finding of
The major risk factor for the development of mesothelioma dysphagia complicating pleural mesothelioma in an elderly
is prolonged occupational or environmental exposure to female cement trader. It also brings to fore the diagnostic dilemma
asbestos3. The latency period from exposure to asbestos and the and fatality that can arise due to a low index of suspicion.

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Nwanji, ID., et al.,

Case Presentation
History and examination findings
The decedent was a 68-year-old Nigerian female who
presented at the University College Hospital, Ibadan, Nigeria
on account of complaints of difficulty in swallowing of three
months duration. The difficulty in swallowing was initially to
solid foods and then gradually progressed to difficulty in taking
liquids. There was associated retrosternal chest pain and weight
loss. There was no history of ingestion of any corrosive substance.
She is a known hypertensive. She did not take alcohol or use
tobacco in any form. She was a cement trader (who had been in
the cement trade for 20 years). Examination findings were those
of a chronically ill-looking elderly woman with significant chest
findings of dull percussion notes, and reduced breath sounds on
the left lower lung zone. The remaining physical examination
was essentially normal.
Laboratory and radiologic investigations
Laboratory work-up showed normal full blood count,
urea, creatinine, and liver function tests. However, there was Figure 1. A - Photomicrograph showing the inferior surface of the left
hypokalaemia with serum K+ value of 2.0mmol/l (normal lung base (double green arrows). There is marked pleural thickening by
reference range is 3.5-5.0mmol/l) and an elevated erythrocyte greyish white tumour (single green arrow).
sedimentation rate of 102 mm/hr (normal reference range is B - Photomicrograph showing cut sections of the lung at the costophrenic
0-15mm/hr.). angle with markedly thickened pleural tissue (black arrows).

Chest X-Ray done showed a homogenous opacity in the left C - Pericardial surface with multiple greyish-white tumour nodules
lower lung zone with obliteration of the left costophrenic angle. (black arrows).
The thoracic computed tomography (CT) scan revealed thickened D- Transverse section at the apical mediastinum showing greyish-white
left pleura with reduced left lung volume. The oesophagus was tumour (single green arrow) infiltrating the posterior aspect of the aorta
dilated. Upper gastrointestinal endoscopy revealed a vague lower (double green arrows). The oesophagus is located anteriorly (three
third oesophageal stricture suggestive of metastatic oesophageal green arrows) and it is free from tumour involvement.
malignancy from a lung primary and a provisional diagnosis
Definitive histopathologic diagnosis
of an oesophageal malignancy was entertained. However, the
oesophageal biopsy done was negative for malignancy. The histologic examination of the pleural mass showed a
neoplasm composed of infiltrative cells disposed in pseudo-
Clinical diagnosis, treatment and patient outcome
acinar patterns. The tumour cells were relatively monomorphic
The patient then had a gastrostomy on account of severe with bland nuclei and moderate amphophilic cytoplasm (Figure
dysphagia. Her clinical condition deteriorated around the third 2A). No cytoplasmic mucin vacuoles were seen. These tumour
week of hospital admission. She developed marked dyspnoea and cells were seen to be infiltrating the wall of the aorta (Figure
subsequently had a cardiovascular arrest. Despite interventions 2B). The underlying lung tissue showed atelectatic changes. A
and intensive care admission, she eventually succumbed to her conclusion of epithelioid mesothelioma of the left pleural was
illness and was certified dead after 25 days of hospital admission. made based on the gross and histologic features of this tumour.
Autopsy Findings
The significant findings at autopsy were in the thoracic cavity.
The left lung and visceral pleura were morbidly adherent to the
parietal pleural at the superior and inferior aspects of the left
hemithorax (Figure 1A). There were areas of pleural thickening
and firm greyish-white tumour noted at the aforementioned
sites. The maximum thickness of the pleura is 1.1cm (at the
costodiaphgragmatic area, Figure 1B). At the left lung apex,
the tumour encompassed the subclavian vessels. There were
multiple tumour nodules seen at the pericardial pleura ranging
from 0.5cm to 1.5cm in diameter (Figure 1C). The tumour Figure 2. A: Photomicrograph of the pleural tissue showing
extended to the midline and involved segments of the thoracic infiltrative, mildly pleomorphic cuboidal cells disposed in
aorta, firmly attaching it to the vertebral bones. The oesophagus; pseudoglandular patterns (Hematoxylin and eosin stain, x 400
however, was free of tumour along its entire length (Figure 1D). magnification).
There was atelectasis of the left lung. The right lung B - Photomicrograph shows sections of the wall of the aorta
was moderately heavy and weighed 650g (reference range: with adventitial infiltration by tumour cells (single black arrow).
280-500g). The cut sections of the right lung showed moderate Double black arrows highlight the tunica intima. (Hematoxylin
oedema and congestion. and eosin, x40).

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Discussion This case suggests that in addition to recognized risks among

construction workers exposed to asbestos, cement sellers/traders
The decedent presented primarily with symptoms of
may also constitute an epidemiologic risk group for developing
dysphagia which is a common presentation of oesophageal
pleural mesotheliomas. Large-scale population based prospective
disorders. Even though the chest imaging showed a lung mass,
studies may be needed to further explore this risk.
the presenting symptom of dysphagia and findings of mild
oesophageal stenosis in the lower third initially was considered Conclusion
as indicative of oesophageal involvement by a primary or
This case describes pleural mesothelioma presenting
metastatic lesion. The biopsies of the constricted portion of
primarily with dysphagia in a Nigerian female cement trader
the oesophagus were negative for malignancy, resulting in a
and highlights the diagnostic challenges and fatality involved
clinical diagnostic dilemma which could not be resolved until
when there is a low index of suspicion. It also brings to bare the
her demise.
need for sustained public health policies, oversight and proper
At autopsy, pleural-based masses involving the apical regulation of the production, sale and use of cements, asbestos
and costophrenic angle and the pericardium were seen. The and other constriction materials.
tumour had also encased and infiltrated the fibrous wall of the
large vessels (including the aorta and left subclavian vessels). Declaration
Regarding the aorta, the tumour caused an adherence of Ethical approval and consent to participate
the aorta to the vertebral wall. Interestingly, no evidence of
Not applicable
direct oesophageal involvement by the tumour was found.
Nevertheless, the close anatomic relationship of the aorta and Consent for publication
the compressive mass effect on the oesophagus must have been
Verbal and written consent was obtained from the deceased’s
responsible for the difficulty in swallowing. Dysphagia is a rare
relatives to present the case for publication.
but recognized complication of advanced mesothelioma and this
may be due to mass effect of the tumour or direct infiltration into Availability of data and material
oesophageal lumen5.
Not applicable.
Histologic sections of the tumour showed features in keeping
Conflicts of interest
with mesothelioma. Mesotheliomas can be histologically
categorized into three main subgroups: epithelioid type, The authors have no conflict of interest to declare.
sarcomatoid type and biphasic type (combining epithelioid and Funding
sarcomatoid features).6 The epithelioid type is the most common
subtype and it shows epithelioid cells with ovoid-to-cuboidal The authors did not receive any external funding in the
nuclei with scanty to moderate cytoplasm6. course of writing and publishing this case report.
The differential diagnoses in this case were oesophageal Author’s contribution
malignancy and primary lung adenocarcinoma. As earlier Authors IDN and OOA performed the post-mortem
mentioned, the oesophageal mucosa was clean along its examination. All authors reviewed the patient’s clinical records
entire length with no evidence of neoplastic involvement. The and autopsy findings and made the definitive histopathologic
differential diagnosis of primary lung cancer was also ruled out diagnosis. Authors IDN and BLA conceptualized the idea of
as the underlying lung tissue only showed features of atelectasis. presenting it as a case report. All authors participated in the
Also, the nuclear features typical of adenocarcinomas such as writing and editing of the final manuscript.
eccentric or overlapping nuclei, vesicular chromatin, nuclear
pleomorphism, and cytoplasmic mucin vacuoles were lacking Acknowledgement
in this case 4. Not applicable
Ancillary investigations like immunohistochemistry can be References
helpful to further confirm this diagnosis. Mesotheliomas are
usually positive for Calretinin, D2-40 (podoplanin) and WT1 1. Hiriart E, Deepe R, Wessels A. Mesothelium and Malignant
Mesothelioma. J Dev Biol 2019;7(2):7.
while negative for epithelial markers such as Ber-EP4 and
MOC-317. These antibodies could not be tested for because they 2. Delgermaa V, Takahashi K, Park EK, Le GV, Hara T, Sorahan
are not readily available locally in a resource-limited setting. T. Global mesothelioma deaths reported to the World Health
Organization between 1994 and 2008. Bull World Health Organ
In this index case, the significant risk factor identified appears 2011; 89(10):716-724.
to be prolonged exposure to cement dust. In many developing 3. Neumann V, Löseke S, Nowak D, Herth FJ, Tannapfel
countries such as Nigeria, regulation of the cement and asbestos A. Malignant pleural mesothelioma: incidence, etiology,
content used in construction materials is limited. This has diagnosis, treatment, and occupational health. Dtsch Arztebl Int
resulted in continued use of adulterated cement, asbestos and 2013;110(18):319-326.
other construction materials with attendant health risks as seen 4. Fels Elliott DR, Jones KD. Diagnosis of Mesothelioma. Surg
in this case. Pathol Clin 2020;13(1):73-89.

In spite of the World Health Organization and International 5. Santos Seoane SM, Yano Escudero R, Arenas García V. An
Labour Organization’s call for the adoption of a program to unexpected cause of dysphagia: pleural mesothelioma. Rev
Esp Enferm Dig. 2019;111(6):494-495.
eliminate asbestos-related disease among nations through a ban
on asbestos-containing materials, much is left to be seen in this 6. Inai K. Pathology of mesothelioma. Environ Health Prev Med
area in the West African sub-region8. 2008; 13: 60-64.

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 Medi Clin Case Rep J | Vol: 1 & Iss:2
Nwanji, ID., et al.,

7. Chapel DB, Schulte JJ, Husain AN, Krausz T. Application

of immunohistochemistry in diagnosis and management of
malignant mesothelioma. Transl Lung Cancer Res 2020;9(1):3-
27.
8. Moda HM., Sawyerr H, Clayson A. What will go wrong has
gone wrong: asbestos exposure risk among construction
workers in Nigeria. Policy and Practice in Health and Safety.
2018;16(2):212-223.