The Imaging Journey of Patients with Malignant Pleural Mesothelioma: Experience of a Tertiary Mesothelioma MDT V. Lam, J. Brozik, A. J. Sharkey, A. Bajaj, D. T. Barnes Glenfield Hospital, Leicester, United Kingdom Exhibit Category: Thoracic Neoplasms
None Disclosures
Learning Objectives Imaging features of malignant pleural mesothelioma (MPM), from presentation to palliation Optimum CT imaging technique Means of obtaining histological diagnosis Role of CT in determining radical versus non-radical surgery Normal and abnormal post-intervention appearances Multi-disciplinary based approaches to managing endstage MPM
Presentation Unexplained unilateral pleural effusion and/or thickening
Pleural protocol Entire pleural and diaphragmatic surfaces required from apices to pubic symphysis 60 second delay 150 mls at 2.5 mls/second 1.5 collimation CT Technique
Common features of MPM Circumferential irregular pleural Interlobar fissural thickening involvement Mediastinal irregular pleural thickening
Uncommon features of MPM Discrete Mediastinal pleural nodule invasion Chest Extension wall invasion beyond and thebony diaphragm destruction Metastases at presentation
Role of MRI in MPM Not routinely used to evaluate MPM Mainly used as a problem solving tool for detecting invasion of vessels, cardiac structures, endothoracic fascia, and diaphragm Modality of choice for those in whom iodinated contrast is contraindicated
PET-CT Adjunct in diagnosis and staging F-18 FDG uptake is higher in MPM than benign conditions 1 Potential use of PET-CT guided biopsies PET-CT can give false positives with infection, inflammation, or after talc pleurodesis
PET-CT Images
Benign or malignant pleural disease Yilmaz et al. 2 : Favour a malignant process when: Nodular pleural thickening Mediastinal pleural thickening Parietal pleural thickening > 1 cm Circumferential pleural thickening Specificity: 97 %, 85 %, 85 %, 97 % Sensitivity: 37 %, 31 %, 35 %, 22 %
Mesothelioma Mimics Talc in chest wall leading to Lung a giant cancer cell with pleural effusion Mucinous cystic tumour reaction
Diagnosis Thoracoscopy 3, 4 Investigation of choice Also allows placement of drains or pleurodesis Diagnostic sensitivity of 94 % for malignancy Percutaneous biopsy The increased sensitivity of thoracoscopy has led to a decreased use of aspiration and percutaneous pleural biopsy
Staging The 8 th edition of the TNM classification for malignant pleural mesothelioma is due to be released by IASLC Important for stratification of patients Treatment options Clinical Trials However, there is relatively poor correlation between CT and final surgical staging
Volumetric assessment Volumetry may be useful for pre-operative assessment 5, 6 Currently, quite labour intensive Computer assisted methods are being investigated
Treatment options All treatment should be thought of as palliative Active supportive care Drain Chemotherapy Cordotomy Surgery
Lung Sparing Pleurectomy Decortication aka Radical P/D aka Extended Pleurectomy/Decortication P/D that removes ALL macroscopic disease Full parietal pleurectomy Visceral decortication extending into fissures Removal of pericardium and diaphragm and reconstruction with synthetic patches
Pleuropneumonectomy, aka Extra Pleural Pneumonectomy (EPP) En bloc removal of pleura, lung pericardium and diaphragm. Reconstruction of pericardium and diaphragm with synthetic patches
Contraindications to radical surgery Involvement of subclavian vessels Peritoneal disease involvement Invasion of Neuroforaminal pericardial Vertebral space body and destruction mediastinum Mediastinal invasion
Follow up normal patch appearances
Complications post surgery Chylous collection Talc pleurodesis in chest leading to emphysema granuloma formation Pneumothorax and wall subcutaneous Diaphragmatic patch rupture post EPD Patch dehiscence *
Percutaneous pleural biopsy
Recurrence - Needle tract seeding
Recurrence - Needle tract seeding n = Incidence of Needle Tract Seedlings 4 Aspiration 55 2 (4%) CT Core-Needle Bx 22 1 (4%) Chest Drain 55 5 (9%) Thoracoscopy 51 8 (16%) Thoracotomy 21 5 (24%)
Progression role of serial CT
Palliative measures - Pleural Drains Removal of fluid may relieve pain and difficulty in breathing Therapeutic drain for malignant mesothelioma spread into the peritoneum
Take Home Messages Radiology is key to management Pleural phase CT is vital CT helps discriminate between radical or nonradical surgery
References 1. Sharif S, Zahid I, Routledge T, Scarci M. Does positron emission tomography offer prognostic information in malignant pleural mesothelioma? Interact Cardiovasc Thorac Surg. 2011; 12(5): 806-11. 2. Yilmaz U, Polat G, Sahin N, Soy O, Gulay U. CT in differential diagnosis of benign and malignant pleural disease. Monaldi Arch Chest. Dis. 2005; 63 (1): 17-22. 3. American Thoracic Society. Management of Malignant Pleural Effusions. American Journal of Respiratory and Critical Care Medicine. 2000; 162: 1987-2001. 4. Agarwal PP, Seely JM, Matzinger FR, MacRae RM, Peterson RA, Maziak DE, Dennie CJ. Pleural mesothelioma: sensitivity and incidence of needle track seeding after image-guided biopsy versus surgical biopsy. Radiology. 2006 Nov; 241 (2): 589-94. 5. Liu F, Zhao, Krug LM, Ishill NM, Lim RC, Guo P, Gorski M, Flores R, Moskowitz CS, Rusch VW, Schwartz LH. Assessment of Therapy Responses and Prediction of Survival in Malignant Pleural Mesothelioma through Computer-Aided Volumetric Measurement on Computed Tomography Scans. Journal of Thoracic Oncology. 2010; 5 (6): 879-884. 6. Chen M, Helm E, Joshi N, Gleeson F, Brady M. Computer-aided volumetric assessment of malignant pleural mesothelioma on CT using a random walk-based method. International Journal of Computer Assisted Radiology and Surgery, 2016; 1-10. doi:10.1007/s11548-016-1511-3
Presenting Author Contact Details Dr Daniel T Barnes Consultant Radiologist University Hospitals of Leicester, Glenfield Hospital, Leicester, UK, LE3 9QP Email: Daniel.T.Barnes@uhl-tr.nhs.uk Phone: 0300 303 1573