Rare Presentation of Pleural Mesothelioma with Associated Dysphagia in an Elderly Female Cement Trader and the Resultant Diagnostic Challenges: A Case Report

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 costodiaphragmatic 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.