Mesothelioma Riham Raafat

Mesothelioma:
A. Benign Pleural Fibroma:
-Pathology:
 Age: 40 years (but children are reported too)
 Size: small discovered accidentally  large & producing symptoms
 Shape: spherical, lobulated, well encapsulated, surrounded by
compressed lung tissue
 Site: from any site in the pleural surface (visceral or parietal),
connected to the pleura with a pedicle or broad base
 L/M: interlaced fibrous tissue + myxomatous degeneration +
mesothelial cells or sub-mesothelial mesenchymal cells (pleomorphism
with few mitotic cells)

-Clinical Picture:
.Symptoms:
 Asymptomatic
 General: fever, chills, hypoglycemia, clubbing up to osteoarthropathy
(all are reversible after surgery).
 Local: symptoms of pressure  progressive dyspnea or pleuritic chest
pain
.Signs:
 May mimic pleural effusion  displace mediastinum
 May mimic pericarditis (constrictive type) due to gross mediastinal
displacement

-Behavior:
 Simple for a long time

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Mesothelioma Riham Raafat

 Invasive (especially after surgical resection)  Anaplastic

Fibrosarcoma
 Recurrence (suspected with return of constitutional symptoms)

-Investigations:
1. CXR: appears as a dense homogenous, spherical and lobulated
opacity anywhere in the pleura (if in fissure appears ovoid) ± seen with
a connection to the pleura by a pedicle or broad base.
2. Biopsy: see pathology.

-Treatment:
Surgical resection as it's a potentially malignant disease (no lung tissue
removed).

B. Malignant Mesothelioma:
-Definition:
It's a cancerous proliferation of mesothelial cells that usually involves a
large extent of the pleural cavity.

-Etiology:
 Asbestos exposure (major risk factor of 80%)  occurs with crocidolite
more with latent period of 30-45 yrs.
 Erionite fiber mineral exposure (more in Turkey).
 Chest wall irradiation (very rare non-industrial cause).

-Pathology:
Mixed Sarcomatous Epithelial Undifferentiated
(Tubulopapillary) polygonal type
1 : 1 : 2 ----
ry
Easiest to Cellular Similar to 2 Sheets of
diagnose as it's fibro-sarcoma adenocarcinoma polygonal or

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Mesothelioma Riham Raafat

a metastasis with myxoma with regularly solid epithelial

from a tumor & acellular ordered cells ± dust cells
with histological collagen or carbon, nuclei
elements (LN, are vesicular with
Bone …etc) no mitosis, dilated
acini appears as
branching fronels
lined with cuboidal
cells
Asbestos bodies seen in the underlying lung tissue supports the diagnosis

-Staging:
Stage I: Ipsilateral only  lung, parietal pleura, pericardium, diaphragm.
Stage II: Local invasion  chest wall, heart, LNs & esophagus.
Stage III: Penetrates diaphragm  peritoneum, opposite pleura, LNs out.
Stage IV: Distant metastasis.

-Clinical Picture:
.General: cachexia, fever, rarely clubbing & rarely LN++
.Local: Signs of pleural effusion + frozen mediastinum (more) or shift to
the contralateral side (rare with massive effusion)  shift of the
mediastinum to the same side (with marked pleural encasement).

-D.D.:
1. Metastatic adenocarcinoma: differentiated by immuno-histochemistry,
CEA, B1 specific glycoprotein.
2. Benign asbestos pleural effusion: occurs in the 1st 20 yrs of exposure,
small, asymptomatic and needs only follow-up.
3. Benign fibrous mesothelioma (pleural fibroma): see before.
4. Pleural thickening or fibrosis: see later.

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Mesothelioma Riham Raafat

-Investigations:
1. Radiology:
a) CXR:
 Large pleural effusion: earliest picture (absent in 20% of cases, can
be bilateral in < 5%).
 Pleural thickening: irregular pleura.
 Pleural nodules: unilateral.
 Asbestos related plaques, calcifications, & parenchymal fibrosis.
 Spread later: pericardial effusion, mediastinal widening, and rib
destruction.
b) CT chest:
 Pleural nodular thickening and encasement later.
 Pleural effusions.
 Pleuro-pulmonary changes in the opposite hemithorax.
 Evidence of local spread.

2. Functions:
a) Spirometry: progressive restrictive pattern
b) ABG: normal up to respiratory failure

3. Thoracocentesis:
a) Chemical:
 Exaudative
 Low PH
 Low glucose
 High hyaluronic acid concentration (viscid fluid).
b) Physical: straw colored, sero-sanguinous or hgic fluid.
c) Cytological: +ve for malignancy in 10% of cases.

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Mesothelioma Riham Raafat

4. Biopsy:
a) Closed: by Abram's needle (non-diagnostic small
insufficient)
b) Open: diagnostic
c) VATS: useful early

-Treatment:
-Curative treatment: None
-Palliative treatment:
 Surgery (with high mortality rate so it's not done): extrapleural
pneumonectomy, pleurectomy & decortication, limited pleurectomy,
or thoracoscopy with talc powdrage.
 Radiotherapy: with some regression and lowering fluid accumulation.
 Chemotherapy (single agent): Adriamycin or Cyclophosphamide.
 Analgesics, palliative thoracocentesis & pleuredesis, O2 &
prednisolone (decreases fever and sweating).

*Pleural Thickening or Fibrosis:

-Definition:
It's a diffuse process involving parietal and visceral layers of pleura with
infrequent involvement of the surface of the lung.

-Etiology:
.Localized type: as a sequence of exaudative pleural effusion of any cause
.Generalized type:
Unilateral Bilateral
-TB effusion -Asbestosis
-Old artificial pneumothorax -Rheumatoid disease
-Hemo-thorax -SLE
-Empyema -Drugs (methyrgide, proctalol)
With Calcification Non Calcified except asbestosis

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Mesothelioma Riham Raafat

-Clinical Picture:
 History of pleural effusion, asbestos exposure.
 Asymptomatic  if unilateral with no lung disease.
 Exertional dyspnea  if extensive bilateral.
 Chest pain (v rare)  suspect tumor not fibrosis.

-Investigations:
1. CXR:
 Localized thickness in the lower zone with obliteration of CP-angle.
 Streaky irregular infiltrations.
 Diffuse thickening.
 Thickening + nodular picture  suspect cancer or mesothelioma
 Atelectasis can be found.
 Calcifications can be seen.
2. CT chest: Done when:
 Mesothelioma is suspected.
 See if there is an underlying lung disease.
 Before surgery.
3. PFT:
 Restrictive pattern
 Normal DLCo
 Low Compliance

-D.D.: from malignant infiltration of mesothelioma.

-Treatment:
.Of the cause
.Pleurectomy & decortication:
 In localized type: only if there is restriction

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Mesothelioma Riham Raafat

 In diffuse type: with pre-operative assessment of underlying lung

disease, persistent disability, hazards of the procedure & lung
functions.