Malignant pleural mesothelioma is an aggressive form of cancer that originates in the pleural mesothelioma. The main pathogenic factor is exposure to asbestos. Histologically, it is classified as epithelioid (60%), biphasic (30%) or sarcomatoid (10%). It generally appears as local disease in the affected hemithorax, and metastases are rare. It is unusual for malignant pleural mesothelioma to manifest with gastrointestinal complications due to metastatic implants. We report a case of jejunal perforation due to malignant epithelioid pleural mesothelioma metastasis.
A 67-year-old man with a history of malignant pleural mesothelioma (T3N2M0) underwent radical pleuropulmonectomy with lymphadenectomy in July 2010. Adjuvant chemotherapy was administered and the patient was followed up by the Oncology department. He presented in the emergency room in August 2011 with a 4-h history of sudden onset abdominal pain, initially in the lower abdomen, but which then became diffuse. On examination, abdominal guarding with signs of peritoneal irritation were observed. Clinical laboratory test results were within normal limits. No significant findings were detected on abdominal X-ray. An abdominal computed tomography with intravenous contrast medium was performed, revealing air in the peritoneal cavity, circumferential wall thickening of a short segment of the hypogastric small intestine (jejunum) with marked inflammatory changes and small adjacent air bubbles (Fig. 1). In view of these findings, emergency laparoscopic intervention with supra and infra-umbilical access was performed, revealing acute purulent peritonitis in the inframesocolic space due to a single perforation of the jejunum at the site of an ischemic lesion. Intestinal resection with manual end-to-end anastomosis was performed and the post-operative period was incident-free. Pathology reported epithelioid malignant mesothelioma metastasis in the intestinal wall and 2 isolated lymph nodes. The patient was referred to the oncology department for treatment with chemotherapy.
A search of the Medline database (1974–2013) retrieved 4 cases of malignant pleural mesothelioma metastasis involving the small intestine1–4 and 1 case presenting as acute jejunal perforation.5 Our patient is the second case with acute presentation described in the literature. Malignant pleural mesothelioma generally manifests as a locally invasive chest tumor, while cases of gastrointestinal metastases are rare, probably because diagnosis is difficult. Abdominal symptoms tend to be unspecific and are often interpreted as side effects of chemotherapy, and the sensitivity of ultrasound and computed tomography (CT) techniques for detecting intestinal tumors is poor. PET/CT and the combination of capsule endoscopy and double-balloon enteroscopy may overcome difficulties in detecting this type of metastatic implant.
In our opinion, the possibility of metastasis to the small intestine must be taken into account in patients with a history of malignant pleural mesothelioma and clinical symptoms consisting of acute abdominal pain, occult fecal blood, and intermittent unspecific abdominal pain.
FundingServicio de Cirugía General y Aparato Digestivo del Hospital Universitario Santa Lucia de Cartagena.
Servicio de Cirugía General y Aparato Digestivo del Hospital Universitario Santa Lucia de Cartagena.
Please cite this article as: Navarro García MI, Sánchez Pérez A, Vázquez Rojas JL. Perforación yeyunal por metástasis de mesotelioma pleural maligno. Arch Bronconeumol. 2015;51:366–367.
