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Case of the Month: March 2008

Differential Diagnosis:

• Metastatic Disease to the Pleura
  • Lung Cancer (36% of all pleural metastasis)
  • Lymphoma (10%) - strong possibility given this patients history of testicular lymphoma
  • Less commonly: gastric cancer, invasive thymoma, leukemia, or renal cell carcinoma)
    
• Primary Malignant Pulmonary Mesothelioma
• Tuberculosis

Definitive tissue diagnosis was obtained with Video Assisted Thoracoscopic Surgery (VATS):

• Malignant Pleural Mesothelioma (MPM): Epithelial Histology
  • MPM is the most common primary neoplasm of the pleura
  • MPM has an insidious onset typically characterized by recurrent unilateral exudative pleural effusion, pleural nodules, masses and/or plaque-like growth with invasion of the fissures and encasement of the lung.
  • In the United States it is reported that:
    • 2,000 to 3,000 new cases of MPM occur each year
    • Up to 80% have prior asbestos exposure history (7% to 10% lifetime risk in heavily exposed individuals) - however this man never reports exposure to asbestos.
      
      • In a series of 31 patients at CSMC, 19 (61%) patients had no history of asbestos exposure
    • Male:Female ratio is between 2-6:1
    • Peak Age: 6th to 7th decade of life
    • Poor prognosis: 85% die within one year of diagnosis
    • Pathology:
      • Epithelial (50%), Mixed (34%) and Sarcomatoid (15%): worst prognosis

References

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Cugell DW, Kamp DW: Asbestos and the Pleura: A Review. Chest 2004;125;1103-1117

Fraire AE. Cooper S, Greenberg SD, Buffler P, Langston C. Mesothelioma of childhood. Cancer 1988; 62:838-847.

Hofmann J, Mintzer D, Warhol MJ. Malignant mesothelioma following radiation therapy. Am J Med 1994; 97:379-382.
Kawashima A, Libshitz HI. Malignant Pleural Mesothelioma: CT Manifestations in 50 Cases. AJR 155:965-969, November 1990

Mesurolle B et al, Unusual radiologic findings in the thorax after radiation therapy. Radiographics 2000; 20:67-81

Miller BH et al. From the Archives of the AFIP Malignant Pleural Mesothelioma: Radiologic-Pathologic Correlation.

RadioGraphics 1996; 16:613-644

Neugut AI et al. Incidence of Malignant Pleural Mesothelioma after Thoracic Radiotherapy. September 1, 1997: Volume 80: Number 5: 948-950

Pisani RJ, Colby TV, Williams DE. Malignant mesothelioma of the pleura. Mayo Clin Proc 1988; 63: 1234-1244.

Pistolesi M, Rusthoven J. Malignant Pleural Mesothelioma: Update, Current Management, and Newer Therapeutic Strategies. Chest 2004;126;1318-1329

Roach,HD et al. Asbestos: When the Dust Settles¿An Imaging Review of Asbestos related Disease. RadioGraphics 2002; 22:S167-S184

Rusch VW, Piantadosi S, Holmes EC. The role of extrapleural pneumonectomy in malignant pleural mesothelioma. J Thorac Cardiovasc Surg 1991; 102:1-9.

Tyszko SM et al. Best Cases from the AFIP Malignant Mesothelioma. RadioGraphics 2007; 27:259-264

Wagner JC, Sleggs CA, Marchand P. Diffuse pleural mesothelioma and asbestos exposure in the North West Cape Province (South Africa). Br J Ind Med 1960; 17:260.

Wang Z et al. Malignant Pleural Mesothelioma: Evaluation with CT, MR Imaging, and PET. RadioGraphics 2004; 24:105-119.

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