Best Case of Malignant Pleural Mesothelioma

Transcription

1 วารสารกรมการแพทย ป ท 41 ฉบ บท 4 กรกฎาคม-ส งหาคม โรคมะเร งเย อห มปอด รายงานผ ป วย อล สา เจนค มวงศ พ.บ.* สล ล ศ ร อ ดมภาส พ.บ.** อ ชพร เพชรด พ.บ.*** *ภาคว ชาร งส ว ทยา โรงพยาบาลราชว ถ เลขท 2 ถนนพญาไท เขตราชเทว กร งเทพมหานคร **โรงพยาบาลมหาวช ราลงกรณ ธ ญบ ร เลขท 139 ต ำบลบ งสน น อ ำเภอธ ญบ ร จ งหว ดปท มธาน ***โรงพยาบาลภ ม พลอด ลยเดช ถนนพหลโยธ น แขวงสายไหม เขตสายไหม กร งเทพมหานคร Best Cse of Mlignnt Pleurl Mesotheliom Chenkhumwongse A* Siriudomps S** Petchdee A*** *Deprtment of Rdiology, Rjvithi Hospitl, 2 Phythi Rd., Khet Rjthevi, Bngkok, (e-mil : lis.chenkhumwongse@gmil.com) **Mhvjirlongkorn Cncer Hospitl, Bueng Snn, Thnyuri, Pthum Thni, ***Bhumiol Adulydej Hospitl, Phhonyothin Rd., Khwng Si Mi, Khet Si Mi, Bngkok, Introduction Mlignnt pleurl mesotheliom (MPM) is n uncommon mlignnt neoplsm tht rises from pleur. Exposure to sestos is the most common cuse of MPM thus the disese is clssified into sestos-relted disese (ARD). Imging studies ply n essentil role in the evlution of mlignnt pleurl mesotheliom. Accurte stging is importnt for ptient mngement. New rdiologic imging modlities, including MRI nd PET/CT, re currently used for stging mesotheliom. This cse is prole exmple of non-occuptionl or environmentl setting ARD. Even though no history of sestos exposure ws otined in this cse, some studies hve shown incresed incidence of mesotheliom in sestos industrilized countries where people cn e exposed to sestos ccidentlly nd incidentlly. So the im of this cse report is to put emphsis on concern out helth prolem in our country

2 128 วารสารกรมการแพทย Cse report History A 76-yer-old mn cme to the hospitl with history of progressive dyspne without fever. He hd worked s n owner of the grocery shop nd gve no history of sestos exposure in his occuption. He hd smoked 20 pck yer for 25 yers nd quit for 30 yers. He did not hve significnt weight loss. He hd no known exposure to tuerculosis or inhlnts. His fther died of lung cncer. Physicl exmintion reveled decresed reth sound on the right side with dullness on percussion. Figure 1 Frontl rdiogrph showed nerly complete hziness of right hemithorx with mild medistinl shift to the left. He ws sent for CT evlution followed y pleurl tpping nd pleurl iopsy. Cytology of pleurl effusion ws negtive for mlignnt cell. Contrst enhnced helicl CT of the chest ws performed with sixteen-detector multisection CT scnner. Coronl nd sgittl 3.0-mm thick sections were reconstructed. The imges demonstrted enhncing circumferentil irregulr right pleurl thickening. There ws only smll clcified lesion t nterior right chest wll pleur. Moderte mount of right pleurl effusion ws detected (Figure 2). This irregulr pleurl plque showed medistinl nd right hemidiphrgmtic invsion (Figure 2 nd 3). Imging findings Initil chest rdiogrphy reveled nerly complete hziness of right hemithorx with mild medistinl shift to the left. The left lung prenchym nd ony structures pper norml (Figure 1).

3 วารสารกรมการแพทย ป ท 41 ฉบ บท 4 กรกฎาคม-ส งหาคม Figure 2 Axil contrsted CT scn showed circumferentil irregulr right pleurl thickening nd moderte mount of right pleurl effusion. No evidence of right lung volume loss or contrction ws seen. There ws smll round clcifiction t nterior spect of right chest wll pleur (rrow). Note medistinl invsion in figure 2. Figure 3 & Coronl reconstruction imges confirmed enhncing irregulr circumferentil right pleurl thickening. Medistinl nd right hemidiphrgmtic invsion ws seen. Pthologic evlution Pleurl iopsy ws done. The pleurl iopsy showed frgments of tumor cells, muscle nd vessels. The tumor cells were in cuoidl shpe, forming in glndulr structure nd microppillry structure. Some tumor cells were in spindle shpe. In high power view, these tumor cells hd round hyperchromtic nuclei with vrition in size nd distinct nucleoli. Rre mitosis ws seen. No ferruginous ody or sestos ody ws detected in H&E stining. In immunohistochemicl study, the tumor cells showed rectivity for WT1, Clretinin wheres non-rect to TTF-1, Npsin-A, Bcr-EP4. These fetures were comptile with mlignnt mesotheliom.

4 130 วารสารกรมการแพทย c d Figure 4 H&E stining. () Low-power photomicrogrph (x40), the iopsy showed frgments of sheets of tumor cells with mixed pttern. () High-power photomicrogrph (x400), these tumor cells formed in tuuloppillry pttern. (c) Some res, the tumor consisted of epithelioid cells with undnt cytoplsm nd vesiculr nucler chromtin with prominent nucleoli (x400). (d) Some res, the tumor cells consisted of spindle cells rrnged in fscicles with izrre nuclei, consistent with srcomtoid pttern (x400). Figure 5 The immunohistochemicl study. () It showed rective for WT1 (rown stining of tumor nuclei), nd () Clretinin (rown stining of cytoplsm), (x400). Figure 6 These figures showed negtive result of immunohistochemicl study for TTF-1 () nd Bcr-EP4 (). (x400)

5 วารสารกรมการแพทย ป ท 41 ฉบ บท 4 กรกฎาคม-ส งหาคม Discussion Mesotheliom is n uncommon cncer tht cn occur from mesothelium lining of vrying sites such s peritoneum, pericrdium, pleurl nd tunic vginlis of testis. 1-2 Mlignnt pleurl mesotheliom (MPM) is the most common type of mesotheliom tht rises from pleur. 2, 3 There is significntly incresed risk of developing this disese in those individuls with prior exposure to sestos nd long ltency period. 4-6 The ltency period for development of MPM is t lest yers fter initil exposure. 5 Smoking does not hve role in development of mesotheliom. 5, 7 Exposure to sestos is the most common cuse of MPM, pproximtely out 80-90% 8. Other etiologic fctors, including exposure to other minerl fiers e.g.erionite, DNA virus e.g. Simin Virus 40, chronic inflmmtion, hereditry, nd irrdition hve een implicted in these ptients. 9 MPM occurs minly in elder men who hve een exposed to sestos nd it my occur decdes fter exposure. 4, 5 Medin overll survivl is short, pproximtely 1 yer. 10 In Thilnd, sestos hs een imported for more thn 70 yers. Currently, the country is the world top 5 in terms of importer nd user of sestos. In 1968, the first cse of pleurl mesotheliom ws dignosed in Thilnd. 11 However, there is no ntionl dt of MPM in countries tht use lrge mount of sestos such s Russi, Chin, Indi nd Thilnd. 12 Therefore, some reserch clculted the 15-yer cumultive numer of mesothelioms during from dt ville for fewer yers nd ssessed its reltionship with levels of cumultive sestos use during They descrie hidden urden of disese of pproximtely 39,000 cses in the 15-yer period to 2008, predominntly in Russi, Kzkhstn, Chin, Indi nd Thilnd. 13 The typicl ptient with MPM presents with chest pin, dyspne nd recurrent pleurl effusion. 14 The comintion of n unexplined pleurl effusion nd pleurl pin should rise the suspicion of MRM, even if the initil cytologicl findings re negtive. 14 Weight loss nd ftigue re common lter in the progression of pleurl mesotheliom Imging studies, including computed tomogrphy (CT), mgnetic resonnce imging (MRI), nd positron emission tomogrphy-computed tomogrphy (PET/CT), ply n essentil role in stging of disese, follow up post tretment nd work up for metstsis. 16 The new stging system from the Interntionl Mesotheliom Interest Group is TNM system tht ws initilly developed to ctegorize like cses into homogeneous prognostic groups to id in evluting new tretment options (Tle 1-3). 17 CT is usully the primry imging modlity used for stging of disese. CT is redily ville nd provides significnt ntomic informtion. MR imging or PET/CT cn e used s the finl preopertive rdiologic exmintion to complement CT, prticulrly in questionle cses. MR imging with gdolinium contrst cn improve the detection of tumor extension, especilly to the chest wll nd diphrgm. 16 PET/CT is useful for the detection of nodl involvement nd occult metstsis. 16 The histologic sutypes of mesotheliom include epithelioid (most common), iphsic or mixed, nd srcomtoid. 18 It is one of prognostic fctors.

6 132 วารสารกรมการแพทย Tle 1 Tumor Descriptors for MPM Descriptor Detils Tx T0 T1 T1 T1 T2 T3 T4 Primry tumor cnnot e ssessed No evidence of primry tumor Limited to the ipsilterl prietl pleur with or without medistinl pleur nd with or without diphrgmtic pleurl involvement No involvement of the viscerl pleur Tumor lso involving the viscerl pleur Tumor involving ech of the ipsilterl pleurl surfces (prietl, medistinl, diphrgmtic, nd viscerl pleur) with lest one of the following: () involvement of the diphrgmtic muscle () extension of tumor from the viscerl pleur into the underlying pulmonry prenchym Loclly dvnced ut potentilly resectle tumor. Tumor involving ll of the ipsilterl pleurl surfces (prietl, medistinl, diphrgmtic, nd viscerl pleur) with t lest one of the following: () involvement of the endothorcic fsci () extension into medistinl ft (c) solitry, completely resectle focus of tumor tht extends into the soft tissues of the chest wll (d) nontrnsmurl involvement of the pericrdium Loclly dvnced, techniclly unresectle tumor. Tumor involving ll of the ipsilterl pleurl surfces (prietl, medistinl, diphrgmtic, nd viscerl pleur) with t lest one of the following: () diffuse extension or multiple tumor foci in the chest wll with or without ssocited ri destruction, () direct trnsdiphrgmtic extension to the peritoneum, (c) direct extension to the contrlterl pleur, (d) direct extension to the medistinl orgns, (e) direct extension to the spine (f) extension to the internl surfce of the pericrdium with or without pericrdil effusion or involvement of myocrdium

7 Tle 2 Node nd Metstsis Descriptors for MPM Descriptor Detils วารสารกรมการแพทย ป ท 41 ฉบ บท 4 กรกฎาคม-ส งหาคม NX N0 N1 N2 N3 MX M0 M1 Regionl lymph nodes not ssessle No regionl lymph node metstsis Metstses to ipsilterl ronchopulmonry or hilr lymph nodes Metstses in sucrinl or ipsilterl medistinl lymph nodes, including ipsilterl internl mmmry lymph nodes Metstses in contrlterl medistinl, contrlterl internl mmmry, ipsilterl or contrlterl suprclviculr lymph nodes Distnt metstses not ssessle No distnt metstses Distnt metstses Tle 3 Stging nd TNM Clssifiction of MPM Stge T N M I T1 N0 M0 IA T1 N0 M0 IB T1 N0 M0 II T2 N0 M0 III T1, T2 N1 M0 T1, T2 N2 M0 T3 N0, N1, N2 M0 IV T4 Any N M0 Any T N3 M0 Any T Any N M1 Fctors tht worsen the prognosis include extensive disese, poor performnce sttus, elevted white lood cell counts, nemi, thromocytosis, srcomtoid histologic finding, high SUV rtios t PET, nd evidence of simin virus 40 in the tumor. 19 This cse is prole exmple of non-occuptionl or environmentl ARD. Even though there is no history of sestos exposure in this cse, there re some studies tht show incresed incidence of mesotheliom in those who were exposed to sestos

8 134 วารสารกรมการแพทย ccidentlly nd incidentlly in sestos industrilized countries. 20 The ptient underwent pllitive chemotherpy, Gemcitine nd Cispltin, ccording to his performnce sttus nd extension of disese. He died of disese progression out 18 months fter dignosis. Conclusion This cse is prole cse of MPM tht non-occuptionl or environmentl setting ARD (sestos-relted disese) ecuse of no other risks from history nd underlying disese. Although pthology shows srcomtoid type or d prognostic fctor, his survivl time is more thn one yer with second line chemotherpy. Finlly, mlignnt pleurl mesotheliom remins clinicl prolem in dignosis nd tretment. So the im of this cse report is to put emphsis on concern out helth prolem in our country. Acknowledgement The uthors wish to thnk Dr. Tndej Sinthuske nd tem from Mhvjirlongkorn Cncer Hospitl for their support. References 1. Mirrshhii P, Pilli K, Chu TC, Pourgholmi MH, Morris DL. Diffuse mlignnt peritonel mesotheliom--n updte on tretment. Cncer Tret Rev 2012 ; 38 : Chekol SS, Sun CC. Mlignnt mesotheliom of the tunic vginlis testis: dignostic studies nd differentil dignosis. Arch Pthol L Med 2012 ; 136 : Chen JL, Hsu YH. Mlignnt mesotheliom of the tunic vginlis testis: cse report nd literture review. Kohsiung J Med Sci 2009 ; 25 : Lnpher BP, Buncher CR. Ltent period for mlignnt mesotheliom of occuptionl origin. J Occup Med: 1992 ; 34 : Selikoff IJ, Hmmond EC, Seidmn H. Ltency of sestos disese mong insultion workers in the United Sttes nd Cnd. Cncer 1980 ; 46 : Goel A, Agrwl A, Gupt R, Hri S, Dey AB. Mlignnt mesotheliom of the tunic vginlis of the testis without exposure to sestos. Cses journl 2008 ; 1 : Mossmn BT, Lippmnn M, Hestererg TW, Kelsey KT, Brchowsky A, Bonner JC. Pulmonry endpoints (lung crcinoms nd sestosis) following inhltion exposure to sestos. J Toxicol Environ Helth B Crit Rev 2011 ; 14 : Sporn TA, Roggli VL. Mesotheliom. In: Rooggli VL, Oury TD, Sporn TA, editors. Pthology of sestos-ssocited diseses. 2nd ed. New York: Springer ; 2004 : Peterson JT Jr, Greenerg SD, Buffler PA. Non-sestos-relted mlignnt mesotheliom : review. Cncer 1984 ; 54 : Aisner J. Current pproch to mlignnt mesotheliom of the pleur. Chest 1995 ; 107 : S332-S Bovornkitti S, Prijynond B, Chtikvnij K, Suwnwili C, Boonprsrn C. Firous Pleurl mesotheliom; report of one cse. Vjir Vejsrn 1968 ; 12 : Suhnnchrt P, Dumviht N, Siriruttnpruk S. Asestos-Relted Disese in Thilnd nd Review Literture. J Med Assoc Thi 2012 ; 95 : S71-S6.

9 วารสารกรมการแพทย ป ท 41 ฉบ บท 4 กรกฎาคม-ส งหาคม Prk EK, Tkhshi K, Hoshuym T, Cheng TJ, Delgerm V, Le GV, et l. Glol mgnitude of reported nd unreported mesotheliom. Environ Helth Perspect 2011 ; 119 : Lee YC, Light RW, Musk AW. Mngement of mlignnt pleurl mesotheliom: criticl review. Curr Opin Pulm Med 2000 ; 6 : Roinson BW, Lke RA. Advnces in Mlignnt Mesotheliom. New Englnd Journl of Medicine 2005 ; 353 : Wng ZJ, Reddy GP, Gotwy MB, Higgins CB, Jlons DM, Rmswmy M, et l. Mlignnt pleurl mesotheliom: evlution with CT, MR imging, nd PET. Rdiogrphics 2004 ; 24 : Ptz EF Jr, Rusch VW, Heeln R. The proposed new interntionl TNM stging system for mlignnt pleurl mesotheliom: ppliction to imging. AJR Americn journl of roentgenology 1996 ; 166 : Tso AS, Wistu I, Roth JA, Kindler HL. Mlignnt pleurl mesotheliom. J Clin Oncol 2009 ; 27 : O Byrne KJ, Edwrds JG, Wller DA. Clinico-pthologicl nd iologicl prognostic fctors in pleurl mlignnt mesotheliom. Lung cncer 2004 ; 45 : S Luo S, Liu X, Mu S, Tsi SP, Wen CP. Asestos relted diseses from environmentl exposure to crocidolite in D-yo, Chin. I. Review of exposure nd epidemiologicl dt. Occup Environ Med 2003 ; 60 :