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Here&#44; we began first-line treatment with a platinum and pemetrexed doublet&#44; and partial response according to RECIST criteria was recorded after 4 cycles&#44; with reduction of the pleural implants and effusion&#44; and low toxicity&#46; Given the clear clinical benefit&#44; treatment continued with single-agent pemetrexed as maintenance therapy with radiological follow-up every 3 months&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">1</span></a> The disease remained stable with optimal oncological control for 2&#46;5 years&#44; when the patient developed pain in the region of the left thigh&#46; Examination revealed increased consistency in the area&#44; which was hard and painful on palpation&#46; A magnetic resonance imaging study performed to rule out a neoplastic process in this region showed a soft tissue lesion involving the whole of the thigh&#44; extending to the gluteus&#46; Radiological characteristics were consistent with secondary involvement &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Given the rarity of the observation&#44; an ultrasound-guided biopsy was performed&#44; confirming metastatic malignant mesothelioma&#46; In view of our patient&#39;s prolonged oligometastatic disease&#44; local radiation therapy to the muscle lesion was proposed&#46; Moreover&#44; because he was clearly benefitting from systemic treatment and in view of the lack of second-line options&#44; he continued the same therapeutic regimen with oncological monitoring for another 12 months&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Our case is an example of the clinical and therapeutic management of long-term pleural malignant mesothelioma which raises 2 points of interest&#58; prolonged survival achieved with the treatment&#44; and the presence of secondary musculoskeletal involvement&#46; Malignant mesothelioma is a rare tumor that is characterized by involvement of the serous membranes&#44; most commonly the pleura&#46; It is traditionally associated with exposure to asbestos&#44; although other risk factors have been identified&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">2&#44;3</span></a> The initial clinical presentation is characterized by pleuritic pain and pleural effusion&#46; Diagnosis is difficult&#44; and depends in many cases on ruling out other entities&#46; Pleural biopsy is required for a definitive diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">1</span></a> Most newly diagnosed pleural mesothelioma cannot be treated locally&#44; and require systemic treatment with chemotherapy&#44; but this tumor is largely chemo-resistant&#44; and therapeutic options are limited&#46; Indeed&#44; consistent data are only available on first-line treatment&#44; and options after progression are currently unclear&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">1&#44;4</span></a> Despite this being a highly aggressive tumor&#44; dissemination is generally local&#44; and symptoms caused by compression and direct invasion cause the patient to deteriorate rapidly&#46; Distant dissemination&#44; as observed in our patient&#44; is much more uncommon&#44; and the development of musculoskeletal metastasis despite control of the pulmonary disease is exceptional&#46; These events suggest that long-term tumors might disseminate atypically to the so-called &#8220;sanctuary organs&#8221;&#44; where the tumor can evade oncological control&#46; More food for thought is that in oligometastatic patients&#44; continuing systemic treatment while adding a local treatment appears to be a valid therapeutic option&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Our case illustrates a pleural mesothelioma with an atypical course&#58; unusual features include the patient&#39;s long survival on oncological treatment &#40;36 months&#44; when mean survival is around 12 months&#41;&#44; and an exceptionally rare site of dissemination&#46;</p></span>"
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Scientific Letter
Muscle Involvement in Long-term Malignant Pleural Mesothelioma
Afectación muscular de un mesotelioma maligno pleural de larga evolución
Patricia Cruz Castellanos
Corresponding author
cruz.patricia@hotmail.com

Corresponding author.
, Teresa González Merino, Javier de Castro Carpeño
Servicio de Oncología Médica, Hospital Universitario La Paz, Madrid, Spain
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Here&#44; we began first-line treatment with a platinum and pemetrexed doublet&#44; and partial response according to RECIST criteria was recorded after 4 cycles&#44; with reduction of the pleural implants and effusion&#44; and low toxicity&#46; Given the clear clinical benefit&#44; treatment continued with single-agent pemetrexed as maintenance therapy with radiological follow-up every 3 months&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">1</span></a> The disease remained stable with optimal oncological control for 2&#46;5 years&#44; when the patient developed pain in the region of the left thigh&#46; Examination revealed increased consistency in the area&#44; which was hard and painful on palpation&#46; A magnetic resonance imaging study performed to rule out a neoplastic process in this region showed a soft tissue lesion involving the whole of the thigh&#44; extending to the gluteus&#46; Radiological characteristics were consistent with secondary involvement &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Given the rarity of the observation&#44; an ultrasound-guided biopsy was performed&#44; confirming metastatic malignant mesothelioma&#46; In view of our patient&#39;s prolonged oligometastatic disease&#44; local radiation therapy to the muscle lesion was proposed&#46; Moreover&#44; because he was clearly benefitting from systemic treatment and in view of the lack of second-line options&#44; he continued the same therapeutic regimen with oncological monitoring for another 12 months&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Our case is an example of the clinical and therapeutic management of long-term pleural malignant mesothelioma which raises 2 points of interest&#58; prolonged survival achieved with the treatment&#44; and the presence of secondary musculoskeletal involvement&#46; Malignant mesothelioma is a rare tumor that is characterized by involvement of the serous membranes&#44; most commonly the pleura&#46; It is traditionally associated with exposure to asbestos&#44; although other risk factors have been identified&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">2&#44;3</span></a> The initial clinical presentation is characterized by pleuritic pain and pleural effusion&#46; Diagnosis is difficult&#44; and depends in many cases on ruling out other entities&#46; Pleural biopsy is required for a definitive diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">1</span></a> Most newly diagnosed pleural mesothelioma cannot be treated locally&#44; and require systemic treatment with chemotherapy&#44; but this tumor is largely chemo-resistant&#44; and therapeutic options are limited&#46; Indeed&#44; consistent data are only available on first-line treatment&#44; and options after progression are currently unclear&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">1&#44;4</span></a> Despite this being a highly aggressive tumor&#44; dissemination is generally local&#44; and symptoms caused by compression and direct invasion cause the patient to deteriorate rapidly&#46; Distant dissemination&#44; as observed in our patient&#44; is much more uncommon&#44; and the development of musculoskeletal metastasis despite control of the pulmonary disease is exceptional&#46; These events suggest that long-term tumors might disseminate atypically to the so-called &#8220;sanctuary organs&#8221;&#44; where the tumor can evade oncological control&#46; More food for thought is that in oligometastatic patients&#44; continuing systemic treatment while adding a local treatment appears to be a valid therapeutic option&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Our case illustrates a pleural mesothelioma with an atypical course&#58; unusual features include the patient&#39;s long survival on oncological treatment &#40;36 months&#44; when mean survival is around 12 months&#41;&#44; and an exceptionally rare site of dissemination&#46;</p></span>"
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Article information
ISSN: 15792129
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