MALIGNANT MESOTHELIOMA


A. PHILIPPE CHAHINIAN, MD
HARVEY I. PASS, MD


CLINICAL FEATURES
The onset of mesothelioma is usually insidious; a common pre-senting symptom is persistent localized pain.PLEURAL MESOTHELIOMA Chest pain or dyspnea is almost constant, although of varying degree.63,214 Pleural effusion is present initially inup to 95% of cases. 63 Later, tumor growth usually results in complete obliteration of the pleural space and encasement of the lung. 93,214,264Cough, weight loss, and fever are not uncommon. In contrast to benign mesothelioma, clubbing is rare and was seen only in 6% of cases. 51 Mediastinal invasion with dysphagia, phrenic nerve paralysis, pericar-dial effusion, and superior vena cava syndrome can occur. 225 Sponta- neous pneumothorax or hydropneumothorax and Horner’s syndrome have been described. 127,206 Progressive invasion of the chest wall often leads to intractable pain. Chest radiographs reveal a variable amount of fluid, with pleural thickening or pleural nodules, often several centimeters in diameter, imposing a scalloped appearance (Fig. 89.2). Predominance at the base is almost constant. In advanced cases, psilateral shift of the mediastinum and retraction of the involved hemithorax are characteristic, unless the tumor volume becomes very large.

63,93 The electro cardiogram (ECG) is abnormal in almost 90% of patients, showing various arrythmias (sinus tachycardia is the single most common change [42% of cases] but also premature atrial or ventricular contractions, atrial fibrillation, or flutter), conduction abnormalities (right-side bundle branch block, left hemiblocks), nonspecific ST-T changes, or left or right hypertrophy. 289 Computed tomography (CT) is most valuable in showing the extent of disease (including chest wall, mediastinum, pericardium, and diaphragm), relative amount of fluid and tumor, involvement of interlobar fissures, and retraction of the involved hemithorax (Fig. 89.3). In addition, signs of asbestos exposure, such as contralateral pulmonary fibrosis and/or pleural plaques, are seen in 50% of cases and pleural calcifications in 15%.202 Furtherstudies are needed to evaluate the role of magnetic resonance imaging (MRI). MRI has been better than CT in showing tumor spread into the fissures, diaphragm, and bony structures, whereas both procedures are equally effective to detect invasion into the chest wall, lung, and mediastinum.

145a Echocardiography is useful to reveal pericardial involve ment, especially if cardiac tamponade is suspected. 289 Uptake of gal lium 67GA citrate by mesothelioma tumors has been experimentally demonstrated, 273 and gallium scan was positive in 43 of 49 patients (88%) with pleural mesothelioma.265 Recently, the role of fluo rodeoxyglucose (FDG) positron emission tomography (PET) imaging has been examined in a cohort of 28 patients with suspected mesothelioma (confirmed in 22). 26b Standardized uptake values (SUVs) were determined from the most active tumor site in each patient. The mean SUV of the deceased patients was 6.6 +/- 2.9, compared with 3.2 +/- 1.6 among the combined survivors. The deceased patients had tumor SUVs that were highly correlated with duration of survival after the PET study. The survival distribution of the high-SUV group showed significantly shorter survivals, compared with the low-SUV group.

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