Malignant mesothelioma presenting as dysphagia diagnosed by endoscopic ultrasound

Malignant mesothelioma is a tumor involving the pleura or peritoneum. It characteristically presents with dyspnea, pleural eff usions and pleuritic chest pain. Its diagnosis is established by pleural fl uid cytology or pleural biopsy [1]. Based on our literature review, there are less than 10 published cases of malignant mesothelioma in which the initial presentation was dysphagia and the diagnosis was established by endoscopic ultrasound (EUS) with fi ne needle aspiration (FNA) [2,3]. An 81-year-old man was referred to our hospital for worsening dysphagia. Th is was associated with unintentional 22 lbs (10 kg) weight loss in the past 3 months. He had underlying severe chronic obstructive lung disease and congestive heart failure. Th e physical examination was signifi cant for cachexia and decreased bilateral breath sounds with occasional wheezing. He had a barium esophagogram which showed midesophageal narrowing. A computed tomography of the chest demonstrated a mediastinal mass (Fig. 1). He underwent an esophagogastroduodenoscopy which showed extrinsic esophageal compression but no evidence of an esophageal mass. EUS demonstrated an extra-esophageal, subcarinal mass that was sampled by FNA (Fig. 2A). Cytology was consistent with malignant mesothelioma (Fig. 2B). In light of his multiple medical comorbidities, the patient opted for palliative treatment. A percutaneous endoscopic gastrostomy tube was placed for nutritional support due to his ongoing dysphagia.