Radiation-Associated Mesothelioma With Mixed Constrictive-Restrictive Physiology After Mantle-Field Radiotherapy.

BACKGROUND: Malignant mesothelioma is a rare late complication of thoracic radiotherapy and may contribute to complex cardiothoracic manifestations decades after treatment. CASE SUMMARY: A 60-year-old woman treated for Hodgkin lymphoma with mantle radiotherapy and chemotherapy more than 40 years earlier presented with recurrent pleuropericarditis, heart failure symptoms, and recurrent pleural and pericardial effusions. Echocardiography and cardiac catheterization suggested constrictive physiology, whereas cardiac magnetic resonance was nondiagnostic. Positron emission tomography-computed tomography showed hypermetabolic pleural, mediastinal, and pericardial lesions. Despite anti-inflammatory therapy and corticosteroids, progressive congestion required near-total pericardiectomy. Histopathology revealed high-grade mesothelioma involving the mediastinum, pericardium, pleura, lungs, and myocardium. Following pericardiectomy, the restrictive component of a mixed constrictive-restrictive physiology became apparent, leading to cardiogenic shock requiring venoarterial extracorporeal membrane oxygenation. DISCUSSION: Radiation-associated malignant mesothelioma is a rare but challenging late complication of thoracic radiotherapy and may contribute to mixed constrictive-restrictive physiology. TAKE-HOME MESSAGE: Survivors of mantle-field radiotherapy for Hodgkin lymphoma remain at risk for both radiation-associated heart disease and secondary malignancies decades after treatment.