Malignant pleural mesothelioma: Role of MDCT in early diagnosis and prediction of resectability for radical surgery

Transcription

1 Malignant pleural mesothelioma: Role of MDCT in early diagnosis and prediction of resectability for radical surgery Poster No.: C-0890 Congress: ECR 2010 Type: Educational Exhibit Topic: Chest Authors: B. Feragalli, V. Di Mizio, F. De Filippis, R. L. Patea, L. Guetti, M. L. Storto; Chieti/IT Keywords: MESOTHELIOMA, PLEURA, COMPUTED TOMOGRAPHY DOI: /ecr2010/C-0890 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 29

2 Learning objectives to describe MDCT protocol optimized for the evaluation of pleural disease; to report MDCT findings that allow Radiologists to suspect a Malignant Pleural Mesothelioma (MPM) at its early stage; to illustrate the role of MDCT in predicting tumor resectability. Background Malignant Pleural Mesothelioma (MPM) is the most common primary neoplasm of the pleura that typically affects individuals occupationally exposed to asbestos through a variety of industries. This tumor has emerged in significant numbers of patients during the last 30 years in the industrialized countries. Because of the latency period, and continued asbestos use in the 1970s, its incidence is likely expected to reach a higher peak between years 2010 and MPM are generally divided into three histologic categories: epithelioid, sarcomatoid and biphasic. Epithelioid mesothelioma constitutes approximately 55-65% of malignant mesotheliomas and the sarcomatoid variant constitutes approximately 10-15%; the remaining mesotheliomas (20-35%) fall into the biphasic category, which evinces features of both epithelioid and sarcomatoid mesotheliomas. MPM is a usually fatal primary neoplasm. The diagnosis of this neoplasm is often made at a late stage and the prognosis is still very poor with a median survival from diagnosis of under a year with supportive care alone. However, recent studies have shown an improved survival after multimodality therapy consisting of extrapleural pneumonectomy followed by radiation and chemotherapy. In selected patients with epithelioid histology and no extrapleural lymph node metastases, results have shown an increase in survival of up to 51 months. This surgery entails resection of the pleura, the pericardium and the diaphragm in addition to the whole lung on that side. Surgery is generally not performed in sarcomatous variants. Early diagnosis and an accurate selection of patients that may benefit from this radical surgery is paramount. To this end, we must recognise the signs of limited MPM that allow Page 2 of 29

3 the diagnosis of this neoplasm at its early stage and, for staging purposes, we have to be able to distinguish between a T3, a locally advanced but resectable tumour, and a T4, an unresectable tumour. Infact T3 describes a locally advanced tumor that is still amenable to surgical resection of all gross disease. In addition to involvement of all the pleural surfaces, there may be areas of tumor extension into the endothoracic fascia or the mediastinal fat. There may be a nontransmural involvement of the pericardium. A solitary, completely resectable focus of tumor extending directly into the chest wall is also included in the T3 category. This focus usually occurs in patients who have a tumor implant in the chest wall at the site of a previous diagnostic thoracentesis, pleural biopsy or thoracoscopy. On the other hand T4 designates a locally advanced and technically unresectable tumor. In addition to involvement of all the pleural surfaces, T4 is characterized by features including diffuse extension of tumor into the chest wall, direct extension through the diaphragm to the underlying peritoneum or direct extension to the controlateral pleura, the mediastinal organs, the spine, the myocardium or the internal surface of the pericardium. Imaging findings OR Procedure details Page 3 of 29

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27 Fig.: 27 Conclusion Mediastinal pleural thickening, volume loss of the hemithorax and extrapleural adenopathy are the most common MDCT findings in pz with MPM Mediastinal pleural thickening, also minimal and focal, should always raise suspicion of MPM, especially when associated with pleural effusion and/or ipsilateral volume loss. MDCT with multiplanar reformations has high diagnostic accuracy in the prediction of tumour resectability, particularly in the evaluation of diaphragmatic involvement and is the primary modality for presurgical assessment of patients with MPM Page 27 of 29

28 Personal Information References [1] Craighead JE, Abraham JL, Churg A et al : The pathology of asbestos-associated diseases of the lungs and pleural cavities: diagnostic criteria and proposed grading schema. Arch Pathol Lab Med 106: , [2] Damhuis RAM, Planteydt HT: Trends in incidence of pleural mesothelioma in the Rotterdam area. Int.J.Cancer 60: 883, [3] Aberle DR, Barnes JR: Computerized tomography of asbestos-related pulmonary parenchymal and pleural disease. Clin Chest Med 12: , [4] Leff A, Hopewell PC, Costello J: Pleural effusion from malignancy. Ann Intern Med 88: , [5] Rusch VW: A proposed new international TNM staging system for malignant pleural mesothelioma. From the International Mesothelioma Interest Group. Chest 108: , [6] Patz EF, Rusch VW, Heelan R: The proposed new international TNM staging system for malignant pleural mesothelioma: application to Imaging. AJR 166: , [7] Marom EM, Erasmus JJ, Pass HI et al The role of imaging in malignant pleural mesothelioma. Semin Oncol 29: 26-35, [8] Miller BH, Rosado-de-Christenson ML, Mason AC, Fleming MV, White CC, Krasna MJ: Malignant Pleural Mesothelioma: Radiologic-Pathologic Correlation. RadioGraphics 16: , [44] Patz EF, Shaffer K, Piwnica-Worms DR, Jochelson M, Sarin M, Sugarbaker DJ, Pugatch RD: Malignant pleural mesothelioma: value of CT and RM imaging in predicting resecability. AJR 159: , [56] Rusch VW, Piantadosi S, Holmes EC. The role of extrapleural pneumonectomy in malignant pleural mesothelioma: a Lung Cancer Study Group trial. J Thorac Cardiovasc Surg. 102:1-9, Page 28 of 29

29 [68] Chang MY, Sugarbaker DJ. Extrapleural pneumonectomy for diffuse malignant pleural mesothelioma: techniques and complications. Thorac Surg Clin 14: , [69] Sugarbaker DJ, Jaklitsch MT, Bueno R, et al. Prevention, early detection and management of complications after 328 consecutive extrapleural pneumonectomies. J Thorac Cardiovasc Surg 128:138-46, [70] Sugarbaker DJ, Garcia JP, Richards WG, et al. Extrapleural pneumonectomy in the multimodality therapy of malignant pleural mesothelioma: results in 120 consecutive patients. Ann Surg 224:288-94, [74] Bonomo Lorenzo, Beatrice Feragalli, Rocco Sacco, Biagio Merlino, Mari Luigia Storto: Malignant pleural disease European Journal of Radiology 34: , [79] Leung AN, Müller NL, Miller RR: CT in differential diagnosis of diffuse pleural disease. AJR 154: , [82] Benamore R.E. et al. Use of imaging in the managemrnt of malignant pleural mesotelioma. Clinical Radilogy 60, , [97] Sugarbaker DJ, Flores RM, Jaklitsch MT, Richards WG, Strauss GM, Corson JM, DeCamp MM, Swanson SJ, Bueno R, Lukanich JM, Baldini EH, Mentzer SJ: Resection margins, extrapleural nodal status and cell type determine postoperative long-term survival in trimodality therapy of malignant pleural mesothelioma: results in 183 patients. J Thorac Cardiovasc Surg 117: 54-65, [102] International Mesothelioma Interest Group: A proposed new international TNM staging system for malignant pleural mesothelioma. Chest 108: , [104] Rusch VW, Godwin JD, Shuman WP: The role of computed tomography scanning in the initial assessment and the follow-up of malignant pleural mesothelioma. J Thorac Cardiovasc Surg 96: , [105] Heelan RT, Rusch VW, Begg CB, Panicek DM, Caravelli JF, Eisen C: Staging of malignant pleural mesothelioma: comparison of CT and MR imaging. AJR 172: , Page 29 of 29