Unusual Region for Pericardial Malignant Mesothelioma: Cutaneous Manifestation in a Turkish Woman
A 37-year-old female patient was admitted with a 10-day history of shortness of breath, palpitation and inability to sleep on her back. The plain chest X-rays showed extensive pericardial effusion. She was a lifelong nonsmoker, and there were no risk factors in her medical history. After the diagnosis was confirmed with echocardiography, the patient was operated under general anesthesia. Pericardiocentesis was performed with midline incision below the sternum. Approximally 500 mL of hemorrhagic pericardial fluid was aspirated. She had significant symptomatic relief after drainage. The mediastinal region was decreased in the follow-up chest radiograph, and echocardiography revealed minimal pericardial effusion. A cytological evaluation of the pericardial fluid was negative for malignant cell or infection. She was discharged with medical treatment follow-up. Approximately 7 months later, she was readmitted to the clinic with complaint of a mass at the incision site (). Ultrasonography revealed a multi-loculated collection (abscess) at the incision site. The patient underwent surgery under local anesthesia, and the mass was removed in its entirety and sent for pathological examination. Histologically, the tumor was composed of neoplastic epithelial cells arranged in irregular tubular and papillary structures that had extensively invaded the muscular and lipomatous tissue. Focal areas were also seen in which atypical cells were arranged in storiform or patternless pattern separated by dense collagenized tissue. Microscopic examination revealed malignant mesothelioma of epithelioid and desmoplastic type. The neoplastic cells were cuboidal and had distinct cell borders, a low-to-moderate nuclear-to-cytoplasmic ratio, pale-to-clear cytoplasm, and pleomorphic round-to-oval nuclei. The neoplastic cells were strongly positive for calretinin and focally positive for Ber-Ep4 and MOC-31. Thyroid transcription factor (TTF)-1 and thyroglobulin immunostaining, which was performed to differentiate from thyroid papillary carcinoma because of papillary proliferation of epithelioid cells, was negative (). On the basis of these findings, the morphological diagnosis was malignant mesothelioma. Positron-emission tomography-computerized tomography (PET-CT) showed increased 18F-fluorodeoxyglucose (FDG) uptake (SUV max: 17.80) in a 53×53×76 mm lobulated mass extending to the paracardiac area of skin beneath the sternum with pericardial thickening (). Lymphadenopathy was found with increased FDG uptake posterior to the body of the pancreas.