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THE PLEURAL-BASED MASS

:
A CASE REPORT AND REVIEW OF
THE LITERATURE
David C. Kunkel, M.D. and Eric T. Cheng, M.D.
Proceedings of UCLA Healthcare (2010)

Presented by : dr. Isti Ferdiana
Lectured
: dr. Irma H Hikmat,Sp.Rad(K),M.Kes

INTRODUCTION
Exposure to asbestos  occupational safety
hazard
Asbestos human carcinogen
Asbestos exposure can be a causal factor in
several other syndromes  benign pleural
plaques
The compromised lung  bacterial and fungal
superinfection

When a focal infectious pneumonitis is located
adjacent to the pleura

clinicians to mistakenly
suspect mesothelioma
based on the radiolographic
appearance of a new
pleural-based mass.

To recognize that a focal. mimicking mesothelioma 2. To avoid premature closure and misdiagnosis of mesothelioma in a patient with known asbestos exposure  tissue histopathology . fungal pneumonitis can present as a pleural based lung mass.The purpose of the present article is twofold 1.

navy veteran  a history of asbestos exposure  Chronic obstructive pulmonary disease (COPD)  Hypertension  Dyslipidemia  Ulcerative colitis  Dyspnea over 2 weeks . 79 year old.CASE REPORT Male.

cough. increased sputum production. chills. Oxygen  desaturation after walking 20 feet.  Denied any Fevers. chest pain.  He used nebulized albuterol twice daily with minimal relief of his symptoms . or weight loss  Stopped smoking 20 years ago.

PHYSICAL EXAMINATION




Afebrile
Oxygen saturation : 92% on 5 ltr (nasal cannula)
Cervical lymphadenopathy (-)
Auscultation crackles in his right lung base,
wheezing (-), stridor (-)
Percussion  no dullnes or use of
accessory muscles with breathing.

 Cardiovascular examination  normal
 Murmurs (-),
 Rubs(-),
 Gallops (-)
Laboratory a white blood cell count of 7.8 x
103/ L, with no left shift.

Chest x-ray 
pleural based soft
tissue mass
the patient was
told he might
have a
mesothelioma
thoracic
computed
tomography(
CT)

. Patient's chest x-ray revealing soft tissue pleural based mass.Figure 1.

CT-guided needle biopsy  Malignancy (-) histopathology  pneumonitis fungal culture Aspergillus fumigatus .inflamed.The CT  diffuse interstitial lung disease . irregularly.a right upper-lobe mass .

Figure 2. revealing diffuse lung disease and right upper-lobe mass . Chest CT with contrast.

(b) A high power view of slide (a) showing the ultrastructure. .Figure 3. (d) The PAS stain. Note the alveoli filledwith necrotic debris. Clockwise from upper left: (a) Aspergillus colonies infiltrating the lung parenchyma. (c) Silver stain showing the hyphae in black. which is characteristic of Aspergillus. Note the branching at sharp angles.

voriconazole complete resolution of the infiltrate NOT MESOTHELIOMA .

DISCUSSION  a pleural-based mass following asbestos exposure is rarely an open-and-shut case of mesothelioma  film x-ray  a pleural-based mass on plain can have multiple causes must never rest solely on the results of imaging  The clinician should always consider a diverse range of diagnoses be aware that the time between asbestos exposure .

Pleural effusion 2. Mesothelioma 4. Local or diffuse pleural plaques 3.The differential diagnosis of a pleural-based opacification in a person exposed to asbestos 1. Infectious pneumonitis . Rounded atelectasis 5.

Pleural Effusion Usually unilateral Exudative a left sided predominance .

irregular . and muscle bundles Pleural plaques  rarely symmetrical. old rib fractures. in the lower 2-3 of the thorax .Pleural Plaques Fibrous tissue calcifications +/-.parietal pleura and the superior surface of the diaphragm Plaques on imaging can easily be confused with sub-pleural fat deposits. Circumscribed or diffuse.

Rounded Atelektasis  when the pleura focally thickens and pinches inward  lung compression and bronchial occlusion that renders the underlying lung airless  This process the appearance of a round. . mass like opacity originating from the pleura.

mesothelioma (latency period is 25 to 40 years following the initial exposure) .Infectious Pneumonitis  Asbestos exposure increases vulnerability to bacterial and the lung tissue's fungal superinfection The healing infection commonly leads to pleural thickening.

step-wise approach in evaluating patients (a history of asbestos exposure dan pulmonary symptoms )  If a pleural mass is seen a tissue sample a diagnosis. Clinicians  a methodical.  Physicians should resist premature mesothelioma diagnosis prior to a definitive tissue sample. .

Terima kasih .

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Indian Journal of Radiology and Imaging.201 .

Different portions of the parietal pleura have received special names which indicate their position in the body. 2. The cervical pleura or (pleural cupula) which rises into the neck. over the apex of the lung. The mediastinal pleura that which is applied to other thoracic viscera. The costal pleura which is the portion that lines the inner surfaces of the ribs and intercostales. 1. 4. 3. . The diaphragmatic pleura which lines the convex surface of the diaphragm.

Indian Journal of Radiology and .

Indian Journal of Radiology and .

Indian Journal of Radiology and .

Indian Journal of Radiology and .

Honeycombing . Air space opacitas 2. Atelektasis 3. Linear and bundle opacities 5. Nodule and mass 4. Nodular and reticulonoduler opacities 7.Clasification of opacification 1. Cyst and bullae 6.

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March 2011. .PLEURAL EFFUSION AMERICAN JOURNAL OF CRITICAL CARE.

AMERICAN JOURNAL OF CRITICAL CARE. .

Lymphatic 2. Increased capillary venous pressure 5.Pathologic collection of pleural fluid is called a pleural effusion. Increased capillary permeability 3. mecanisms : 1. Increased negtive intrapleural pressure . Decreased plasma colloid osmotic pressure 4.

AMERICAN JOURNAL OF CRITICAL CARE. March 2011 .

LOCAL OR DIFFUSE PLEURAL PLAQUE European Respiratory Journa .

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European Respiratory Journal .

sitokin. Interleukin 1 dan as. .arakidonat  inflamasi alveoli berlebih  reaksi jaringan  fibrosis yang progresif.Patofisiologi asbestosis Inhalasi serat asbes  tersimpan di bronkioli dan alveoli  cedera sel epitel dan sel magrofag alveolar ( yang berusaha memfagosit serat )  serat masuk ke jaringan intersisium melalui makrofag/ epitel  makrofag rusak  reaktitive oxygen sepesies (ROS)  merusak jaringan. TNF.

European Respiratory Journal .

associated with pleural thickening and pleural plaques (yellow arrows) consistent with asbestosrelated pleural disease. .ROUNDED ATELEKTASIS Axial enhanced CT scan of the chest shows a nodular-area of increased density (blue arrow). Red arrow point to "comet tail" density that surrounds rounded atelectasis.

European Respiratory Journa .

(a) High-power photomicrograph demonstrates conidiophores with the characteristic head appearance and minute spores. (b) Medium-power photomicrograph shows septate hyphae branching at an angle of approximately 45°. .INFECTIOUS PNEUMONITIS Aspergilus Microscopic features of A fumigatus.

Allergic bronchopulmonary aspergillosis (ABPA) 2. Angioinvasive aspergillosis ( radiograpics 2001) . Pulmonary aspergilosis represents a common. Invasive aspergillosis 4. semi-invasive aspergillosis 5. potentially lethal opportunistic infection that has four unique forms: 1. Aspergilloma 3.

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ABPA .

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ASPERGILOMA .

RadioGraphics 2001 .

RadioGraphics 2001 .

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Invasive Aspergilosis .

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Semi invasive Aspergilosis .

. (a) Coronal diagram shows diffuse pleural disease on the left side of the chest and a solitary pleural mass in the right hemithorax.PLEURAL TUMOR Diffuse and solitary pleural tumors.

b) Transverse diagram demonstrates disseminated nodular pleural iiimon with effusion in the left hemithorax and a focal right .

MESOTHELIOMA .

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Radiologic Evaluation of Malignant Pleural and Peritoneal Mesothelioma Radiologic Findings Pleural Effusion Pleural Thickening Pleural Calcification Rates 85.7 % Thickening of Interlober Fissur Reduction in Thoracic Volume Mediastinal Lymphadenopathy 47.12 % 100 % 40.7 % .6 % 40.7 % 29.

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Common primary sites are from lung. and ovary . breast.PLEURAL METASTASE Adenocarcinomas are known to cause pleural metastasis more frequently than other histological types of cancers. lymphoma.

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Spikula 12. Destruksi tulang 6. Metastasis 8. Pendesakan diafragma 9.13 Tanda massa Paru 1. Emfisema 3. Efusi pleura 5. infiltrasi 7. Penebalan septal 13. Konsolidasi 11. Atelektasis 4. Pembesaran KGB 10. Acute angel . Nodul/ massa 2.

Efusi pleura 5.Tanda massa pleura 1. Letak di perifer 2. Reaksi infiltrat (-) 3. Obstuse angle terhadap dinding thorak . Destruksi tulang 4.