Diagnosis and management of pleural mesothelioma: three unique cases and review of the literature

Mesothelioma is a rare pleural tumor. Compared to diffuse pleural mesothelioma, localized pleural mesothelioma carries a better prognosis and may be managed with surgical resection. Among histologic subtypes, the sarcomatoid variant is the least common but is associated with the poorest outcome. Diagnosis remains challenging, with immunohistochemistry playing a central role in confirming the disease. While surgical resection is the cornerstone of management, chemotherapy, immunotherapy and radiotherapy are considered in unresectable cases. Overall, mesothelioma continues to carry a poor prognosis. We describe three cases of pleural mesothelioma that posed diagnostic and therapeutic challenges. The first case involved a rapidly progressive sarcomatoid mesothelioma, initially raising concern for Ewing’s sarcoma, which was excluded based on negative immunohistochemical markers. The second case was an epithelioid mesothelioma successfully treated with extrapleural pneumonectomy followed by adjuvant chemotherapy and immunotherapy, resulting in prolonged survival. The third case, the only one with documented asbestos exposure, represents the first reported instance of synchronous epithelioid mesothelioma and invasive ductal carcinoma of the breast. Mesothelioma is a rare and complex pleural malignancy that may present in atypical ways, complicating both diagnosis and management. These cases underscore the importance of immunohistochemical profiling, highlight the value of multidisciplinary diagnostic approaches, and reaffirm the pivotal role of surgery within the therapeutic algorithm.