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Uncommon Manifestations of Common Malignancies

CASE 1. Soft-Tissue Metastases From Malignant Pleural Mesothelioma

Department of Medical Oncology and Hematology, Division of Pathology, Division of Diagnostic Radiology, Istituto Clinico Humanitas, Rozzano-Milan, Italy

A 53-year-old man was diagnosed with malignant epithelial pleural mesothelioma after Tru-Cut biopsies of left parietal pleura and left supraclavicular lymph node. His clinical stage was III according to International Mesothelioma Interest Group classification. He received first-line chemotherapy with six courses of cisplatin and vinorelbine achieving partial remission. Nine months later, progressive disease was observed in mediastinal and bilateral supraclavicular lymph nodes; thus, radiotherapy (40 Gy) was performed on these sites. About 1 year later, the patient presented with contralateral lung disease and retroperitoneal masses. He received eight courses of multitarget antifolate therapy with disease stabilization. Two months later he underwent a chest and upper abdomen computed tomography scan that showed stable disease. However, he developed pain in the left buttock, and examination disclosed a fixed intramuscular mass. Magnetic resonance imaging showed a well-defined 4 x 2.5-cm mass in the left buttock, as well as another tumor mass in the left psoas muscle (Figs 1A and C, before, and B and D, after gadolinium-diethylenetriamine pentaacetic acid injection; arrows, psoas and gluteus metastases). Musculoskeletal metastases from malignant pleural mesothelioma to the chest wall due to direct extension, as well as distant sites after extrapleural pneumonectomy, have been described.^1-3 However, soft-tissue distant locations are very infrequent. A Tru-Cut biopsy was performed, which revealed an infiltration of gluteal muscle by a malignant proliferation of epithelioid cells having a pseudoglandular pattern of growth interspersed within muscle fibers. Immunophenotype of the neoplasm (calretinin, epithelial membrane antigen, and cytokeratin AE1/AE3-positive and carcinoembryonic antigen–negative) was decisive,⁴ and the diagnosis of metastasis from epithelioid malignant mesothelioma was made (Figs 2A and B). The patient then received six cycles of chemotherapy with an antracycline regimen, achieving partial remission of the buttock lesion and stabilization of thoracic disease. Unfortunately, eventual progression of thoracic disease and retroperitoneal lymph node metastases with ascitis occurred.

View larger version (141K): [in this window] [in a new window]   Fig 1.

View larger version (52K): [in this window] [in a new window]   Fig 2.

The authors indicated no potential conflicts of interest.

REFERENCES

1. Baldini EH, Recht A, Strauss GM, et al: Patterns of failure after trimodality therapy for malignant pleural mesothelioma. Ann Thorac Surg 63:334-348, 1997[Abstract/Free Full Text]

2. Szklaruk J, Tamm EP, Choi H, et al: MR imaging of common and uncommon large pelvic masses. Radiographics 23:403-424, 2003[Abstract/Free Full Text]

3. Marom EM, Erasmus JJ, Pass HI, et al: The role of imaging in malignant pleural mesothelioma. Semin Oncol 29:26-35, 2002

4. Ordonez NG: Immunohistochemical diagnosis of epithelioid mesotheliomas: A critical review of old markers, new markers. Hum Pathol 33:953-967, 2002[CrossRef][Medline]

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