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FILE NAME Household Contact HC DATE 1970 DOC HC026 DOCUMENT DESCRIPTION Journal Article - The Radiological Manifestations of Malignant Pleural Mesothelioma Vol 108 No. I THE RADIOLOGICAL MANIFESTATIONS OF MALIGNANT PLEURAL MESOTHELIOMA By RICHARD M. HELLER M.D. MURRAY L. JANOWER M.D. and ALFRED L. WEBER M.D. Headley BOSTON MASSACHUSETTS ermissionaBaan paper bypee e British 4 MALIGNANT pleural mesotheliomas represent MALIGNANT small fraction of primary TABLE I SUMMARY OF FINDINGS ermission 4 ~} Baclesse 3 x Brit J alculation of . Staff Meet imum utiliza zing survival malignant tumors arising in the chest Interest has been stimulated in this entity because of its apparent relationship to asbestos exposure The difficulty in establishing the correct diagnosis is attested to by the large number of reported cases in which the correct diagnosis is made only at autopsy It is hoped that review of a representative series of cases may reveal a constellation of clinical and radiologic features which will permit the radiologist to suggest the correct diagnosis A review of the charts and roentgenograms of 10 Age 34-74 years average= 58 years Sex 8 male 2 female Asbestos exposure 6 patients Chief complaint Dyspnea .....6 Pain cece .4 .4 Cough 2 Weight loss 2 Hoarseness 1 Diagnosis established Thoracotomy 5 Needle biopsy 2 Autopsy 1 Liver biopsy 1 Prognosis Seven dead Average dead diagnosis Average of symptoms was within 3 months of duration from onset ee eee ee eee eee 14 mo sopharynx 7 , We abeas po ows cases of malignant pleural mesothelioma seen at the Massachusetts General Hospital from 1960 to 1967 forms the basis of Three alive 2 with persistent tumor No residual tumor 6... eee cree 8 41 mo eens 44 mo ur this report Physical examination was not helpful C C CLINICAL FEATURES in establishing the diagnosis The only Relisdean The average patient age was 58.2 years pborseiattihvesofuinnddsingasnd cdounlslinsetsesd toofperrceudsuscieodn with an age range of 34 to 74 years Table ) There were 8 males and 2 females Of in 3 patients the 10 patients 6 had a history of asbestos The difficulty in establishing the diag- and 2 of these had definite pul- nosis premortem was well demonstrated in exposure a monary asbestosis 1 of whom was a woman the series In 5 patients the diagnosis of mesothelioma was established by thorac- . ita whose exposure was obtained through An additional patient underwent 2 inte washing her pipefitter husband's dusty otomy thoracotomies the pathologic Can work clothes Five of the patients were separate 1 heavy cigarette smokers 3 did not smoke diagnosis on the specimens obtained was Le and no smoking history was available in 2 dense fibrotic pleuritis The diagnosis RIDE RA The most common symptom was dysp- was finally established by liver biopsy ten nea which was reported by 6 of the pa- performed through a peritoneoscope wry tients The chief complaint in 4 patients Needle biopsy of the pleura was per- was chest pain this was not localized to formed in 3 patients with the correct diag- In eawrunat the of the tumor and was pleuritic in nosis established in 2 of them 2 patients ae site type only 2 of the patients All patients the correct diagnosis was only established in had either pain or dyspnea and 3 patients at autopsy One of these patients had a had both negative pleural biopsy the second patient symptoms * General Hospital and Harvard Medical School Boston Massachusetts the Departments of Radiology Massachusetts at Children's Hospital Medical Center From Resident in Radiology Massachusetts General Hospital Presently Massachusetts General Hospital in Radiology Harvard Medical School Assistant Radiologist Massachusetts General Hospital Instructor Clinical Associate in Radiology Harvard Medical School Associate Radiologist 53 54 Heller Janower and Weber JANUARY JANUARY JANUARY 197 , a : fi i . FIG The right hemithorax FIG The 1. entire entire by a large pleural hemithorax is opacified is opacified effusion had an incorrect diagnosis of adenocarcin oma made from a specimen obtained at bronchoscopy The results of therapy consisting consisting of surgery radiation therapy or both have been disappointing Seven of the patients have died 5 within 3 months of diagnosis Tofhe average duration of illness from onset symptoms Three until death was 14 months: patients are living but 2 have known persistent disease The sole survivor with- out disease has lived 44 months following local excision of a small lesion re) Fa 3. There is loculation of pleural fluid along right superolateral chest wall Fluid is also the evideni in the right and left costophrenic angles : = RADIOLOGIC FINDINGS Review of the initial chest chest roentgend grams revealed 3 patterns 1 pleural effusion in 4 patients 2 irregularly a . | ' FIG 2. Large right pleural effusion with a convex superior border FIG 4. Pneumothorax demonstrating thickened i 3 pleura along the lateral chest wall wee Vol 128 No. Malignant Pleural Mesothelioma 55 thickened pleura in 4 patients and 3 mass lesions that appeared pulmonary rather than pleural in 2 patients The pleural effusions varied in amount and configuration Two cases had small bilateral pleural effusions which progressed during the illness There was opacification of the total hemithorax Fig ) in 1 patient and opacification of half the hemithorax in the other The effusions were somewhat atypical in 1 case the fluid was convex superiorly Fig 2 while in the other the lateral border of the fluid formed a more vertical line with the lateral chest wall than is usually seen in uncomplicated pleural effusion The pleural fluid was often loculated Fig 3 Two patients developed pneumothoraces following thoracentesis and irregularly thickened pleura was then readily demonstrable Fig 4 In one of these cases tumor could be seen involving the partial pleura along the lateral chest wall and the visceral pleura over the par- tially collapsed lung Fig 5 The second group of 4 cases presented with irregularly thickened nodular pleura In 2 cases the entire right lateral chest Fig demonstrating Fig 5. Pneumothorax demonstrating thickened nodular parietal and visceral pleura wall showed irregular pleural thickening which extended over the apex of the lung as well as over the diaphragm Fig 6 A and B In of the cases a patient with EES LTE AG C8 AES SS - Sg tron cae cs Eat ie Mes 6. Mesothelioma with asbestosis 1963 A Thickened pleura along the lateral chest wall with ex- FIG nedned over the right hemidiaphragm and lung apex Interstitial fibrosis is apparent B Detailed view tension tension the thickened nodular pleura 56 Heller Janower and Weber JANUARY ey Tae FIG 7. Mesothelioma with asbestosis ( 1966 eRe A Thickened pleura pleura and elevation of the right hemidiaphragm hemidiaphragm B Calcified wrt, diaphragmatic pleura ne Small pleural nodular densities C LE +s SER Be th me See asbestosis the diaphragmatic leaf appeared The fluoroscopy a elevated and was fixed at Fig diaphragmatic leaf also had a lobulated 74 and dense linear bands of contour and there was obliteration of the ae were present in the pleura calcification the vertebrophrenic angle The underlying lung leaf of the diaphragm Fig 7oBveTrhere right showed minimal but definite fibrosis and were multiple small nodular densities that there was destructiondestruction of the right third and fourth ap- peared to be pulmonary but at ribs anteriorly anteriorly Fig 8B were found to be pleural autopsy metastases The fourth case demonstrated demonstrated a 1 cm 7C In both cases the lung fields Fig revealed oblong mass adjacent to andand eroding the a moderate amount of diffuse fibrosis superior surface of the right right sixth anterior rib In the third case there were large lobula- me tions measuring up to 3.5 cm in width Solitary masses that appeared to be in the left eet which extended along the lower thirds tients Onueppoefr lobe were present in a pa- of the right laterallateral chest wall Fig 84 in in diameter the masses measured 25 cm OER and was thought to be a large 57 2 57 No. Malignant Pleural Mesothelioma 57 57 158 We Rhy dee Pes FIG 8. 4 Large lobulated pleural mass B Detailed view showing rib destruction arrow Te ON baht amas fe s feted Fans eens megpre gtd ve fe ! lated bronchiogenic carcinoma Fig 9 7 and B The other mass measuring 3 cm in diam- eter was thought to be in the peripheral Jung parenchyma Fig 10.1 The margins of both masses were irregular but distinct and no cavitation or calcification was pres- ent within them In spite of laminagraphy Fig 10B and chest fluoroscopy it was not apparent that these masses arose from the pleura rather than lung DISCUSSION Pleural mesothelioma is a tumor that occurs predominantly in the adult male population after the age of 40 years The most common symptom is dyspnea fol- FIG 9 .4 and B A large lobulated mass is present at the left apex The left second posterior rib is destroyed 58 Heller Janower and Weber JANUARY 197 ow 4 wD ' & & mam a es es rane + e s - Fig 10. 4 Small nodule superimposed on the lateral aspect of the left posterior fifth interspace arrow B Laminagram demonstrates the nodule lowed in frequency by nonspecific chest pain The pain may be severe when associ- ated with bone destruction Of the 10 cases studied 2 had pulmonary asbestosis while 4 others had exposure to asbestos Reports in the literature indicate a pathogenetic relationship between ex- posure to asbestos and development of pleural mesothelioma The diagnosis of pulmonary asbestosis is confirmed by the presence of asbestos bodies in the lung Fig 11 pleura or occasionally in the mesothelioma Fibrosis in the lower lung fiekis associated with pleural thickening and in some instances pleural calcifica- tion are important parameters in the radio logic diagnosis of asbestosis The correct diagnosis is often established by needle biopsy or open thoracotomy However in a large number of cases the diagnosis is not established during life but I at autopsy In these cases the diagnosis may not be suspected during life or the amount of tissue obtained from a needle i biopsy is too small In one case 2 biopsy specimens were interpreted as fibrous 1 pleuritispleuriti, s indicating indicating that each time thick- ft ened pleura rather than tumor was biop- sied The entity of mesothelioma is well accepted among pathologists although it may be difficult to distinguish between a mesothelioma and an anaplastic cancer of 1 the lung Two broad categories are gener- ally recognized epithelial and the fi- brosarcomatous type In some cases there 1 may be a combination of both. Mesothelioma can invade the lung parenchyma When the tumor progresses jt cavity may encase the entire thoracic Extension of tumor occurs to the medi astinum pericardium liver and occasionally into the opposite pleural cavity Hilar and mediastinal lymph nodes may be in- . VOL 108 No. 1 Malignant Pleural Mesothelioma 59 volved but this is usually a late finding : a and not recognized on the chest roentgen- Set as : ogram Metastases to distant organs such Big bones lymph nodes or brain have been pes encountered Most of these metastatic de- Deply posits are found at autopsy SS PeetyrGR Mesothelioma is manifested radiologi- OOI e erasESeP cally in 3 ways pleural effusion by Spool ll irregular pleural thickening or as a nodular ealntidhcaAiantosoie mass lesion tele In pleural effusions the inner margin of the fluid is often irregular and a convex hump may be seen Loculation of fluid SenneWnit - is demonstrated when upright and decubirds er fluid us _ tus roentgenograms are obtained Follow- ade tt ing paracentesis the may recur and sinrate may opacify the entire hemithorax The pet fluid is usually bloody but a serous effusion ane may be found Mae Irregular nodular thickening of the pleura may extend along the entire pleural a erates cavity or may be confined to limited area rena edtive If nodularity is present it is highly sugges- edtive edtive of the diagnosis particularly when associated with chest pain Bone destruc- tion in the area of thickened pleura is strong radiologic evidence of the diagnosis The third type of mesothelioma mani- fests as a nodular density often in the per- _ ipheral lung and is sometimes mistaken Oe a 3 for a lung tumor Only by surgery and uss om _ pathologic examination can the correct Ls diagnosis be established Laminagraphy = we wk may solve the problem but occasionally / even this method cannot differentiate a i lung tumor from a tumor originating in the =- ae pleura is The prognosis in these described cases os is poor 7 of our 10 cases have died 2 are er alive with recurrent disease following sur- ere er gery and radiation therapy and only 1 patient is cured 44 months following ex- beth cision It is of interest that in the latter ay case the patient was asymptomatic and the lesion was nodular and small in size SUMMARY Pleural mesothelioma is a frequent enough tumor to be considered in the dif ferential diagnosis of chest tumors The most characteristic symptoms are pain and dyspnea A history of asbestos exposure or pulmonary asbestosis should alert the radiologist to the possibility of an existing or developing pleural mesothelioma The important radiologic manifestations are 1 pleural effusion often recurrent 2 irregular nodular pleural thickening with or without bone destruction and 3 a nodular density frequently in the peripheral portion of the lung The prognosis is poor Of the patients studied 7 died 2 are alive but have persistent disease and I patient with a small nodular lesion is cured 44 months following surgery Murray L. Janower M.D. Department of Radiology Massachusetts General Hospital Boston Massachusetts 02114 REFERENCES 1. ACKERMAN L. V. and del Regato J. A. Cancer Diagnosis Treatment and Prognosis C. V. Mosby Company St. Louis 1962 p 499 2. FREUNDLICH I. M. and GREENING R. R. Asbestosis and associated medical problems Radiology 1967 89 224 229 3. HURWITZ M. Roentgenologic aspects of asbestosis Am J. ROENTGENOL Rad Therapy & NUCLEAR MED 1961 85 256-262 4. KAUFFMAN S. L. and STOUT A. P. Mesothelioma in children Cancer 1964 17 539-544 5. RATZER E. R. POOL J. L. and MELAMED M. R. Pleural mesotheliomas clinical experiences with patieTHERAPY pnatt iens ts Am J. ROENT- GENOL RAD THERAPY & NUCLEAR MED 1967 99 863-880 6. SANDERS D. E. Pleural mesothelioma 7. Canad A. Radiologists 1968 19 64-73 7. SELIKOFF I. J. Occurrence of pleural calcification among asbestos insulation workers Ann New York Acad 1965 132 351 367 8. SELIKOFF I. J. CHURG J. and HAMMOND E. C. Asbestos exposure and neoplasia J.A.M.A. 1964 188 22 26 9. Selikoff I. J. Churg J. and Hammond E. C. Relation between exposure to asbestos and mesothelioma New England J. Med 1965 272 560-565