Forensic Pathology Case Studies


CASE 3: Pleural malignant mesothelioma with asbestosis


Clinical History:

A 68-year-old man presented to his physician with increasing shortness of breath that he had experienced for several months. He had a 20 lb weight loss in the last month. He has a 100 pack/year history of smoking. He has lived all his life in the U.S. He has worked as a real estate agent for many years. Earlier in his career, he also spent time remodelling the homes he sold. His hobbies include gardening and woodworking. A chest x-ray showed diffuse interstitial disease along with left pleural thickening without an effusion. A pleural biopsy was performed. Two months after the biopsy, his respiratory status worsened and he died.

Image 3.1:

The gross appearance of the left lung is shown here.
At autopsy, the pleura was markedly thickened by an encircling tumor mass that compressed the remaining lung.

Image 3.2:

This is the microscopic appearance of the pleural surface of the opposite lung.
There is dense fibrous collagenous thickening in a pleural plaque.

Image 3.3:

The microscopic appearance of the pleural biopsy is shown here.
Neoplastic cells characteristic of a mesothelioma are present. This must be correlated with the chest radiograph before a diagnosis of mesothelioma can be made.

Image 3.4:

What is this structure seen in the lung parenchyma at high power?
This is an asbestos body. The thin asbestos fiber becomes coated with iron (hence the name "ferruginous body" when seen on an iron stain).

Questions:

  1. What is his disease process?

    2. He has asbestosis.

  2. What is the name of the pleural lesion?

    3. This is a pleural plaque. Such plaques suggest a pneumoconiosis, particularly asbestosis.

  3. How does his history relate to this?

    4. The only suggestive history is that of his working in home remodelling. Many older homes have asbestos-coated insulation around plumbing pipes and in ceiling tiles (the ones with small holes in them). Proper removal of asbestos must be done with proper equipment and procedures (and is very expensive). Even a short time of exposure to asbestos can lead to asbestosis. Shipyard workers in World War II were heavily exposed to asbestos. Brake linings used to contain asbestos.