Document 8GxwdVdpdR2DOjq6ny0BNjvB

FILE NAME: Z//E DATE: DOC#: /E DOCUMENT DESCRIPTION::ZDZZ ZZ/ZZZ^ '.'.IESOTIJJ-:1.i<>\f \ l.'\ /\'/Ji\ I\< I T \! 1: lHESOTHELIOMA Ii\ A\ .\(;fUClJLTlJUAL COM1'llJNITY OF ll\lHA: A CLINICOPATHOLOGICAL S'ITHY P. 13. J),\s, 1 i\. (;, FLE'f'('fllii, iR~ \'.'D s. G. DEODIL\RE3 , Departments of Cardiotlzoraric SurgcrJ and 1.:: f'atlzolo,11y, 1Va11/,ss flos/'i!ai, Jlirai J!cdi(<il College. Maharashtra. India :llcwtltcli111/i<l is ti/I 1111.-0111111011 11,'o/1/aslic l'011dition. Its asso, iatio11 <.;ith .1sl1cslu {'Xpos11rc is well 1stu/Jlishcd, b1tt it Offll1'S n1rn in izo11 .. i11d11stri!I/ 'i\ 1>rkrs. rn:d 1111/ura!/1 thrrc 11t!1.1t /Jc :"n11,: !'t/1cr factors i1! its 1ctiology t/1<111 asli<stos 1'.t'f'os111,., /11 !his retort, fi-~e patients wzlh pnm11ry mesolhc/1011111, all belo11ging to a rural ag1irnlfltral cc,1111111111ity with no chance of a11:i,1 asbrstos exposure, hmc bcr11 documcJttrd. There ;:as 011<' co111111on hitercstiu.u ol>scnl(lfion, in that all fi1Jc patie1Us u<erc associated ;,it/, rnc11r-: mr farming or an a!/icd !rode. H'l1<'1hcr this obscrzatiC111 is coi11ridC11ta/ or lias a111 ;,~/i,.J,,,1i,-.:/ beari11g 011 111,sotlzc!io111a !lccds fmt/wr imrstiqation. Its histof'nlhofo:ir.al frot111c.c. \'_\tnt/)lon1u!o/11yv, dit1.r1nosis, and !rt'ufn1111f UYt' disorsscd, 'Hith a !1 ri('f rc~it"i.l' <;/ t/11' !(t!'rlfi!rc l\'Ii-:sonrELIO\I.\ is an 1mcrn11mo11 ncupbstic cullclition arising fr0111 the pleura and also rarrh' frnm other srrous memhranes. Its incidence has hern reported to range hrhYCen 002rJ, and n2% of all autopsies. with a 2 : 1 lllak prcpomlcrance (Dorr11w ct alii. HJn). .\!ter \Vagner pul1lislwd an account ('f ilie first doc1rnwnicd ca~(' uf primary diffuse rnesotheliorna in 1870. 011lv rel::ttivcl\' few case s reports appcrtrcd in the. literature. till H)6o ( Oels ,f alii. i fJ7 I). H( 1\V("\er. the prtst 1 years have sten niany ~eriPs pnhlished, though none of thetn coukl really he called hrg('. Pxcept tho:;c of 'vVag11cr et olii (I 1yio). 0l'ls et alii ( r971) and Borrow et aTii ( 1973). flicsothclioma is of special interest heca11se of its known induction h_v occupat inn al exposure to asbestos ( Grm1dy and Miller. 1972). Exposure to asbestos as an important ca11:.:ati \'C factor 'Associate Professor and Head of the Department of Cardiothoracic Surgery. 2 Professor of Surgery and H<ad of the Department. 8 Professor and Head of the Dq>artmcnt of Pathology. Address for all communications and reprints: Dr P. B. Das, M.S., F.R.C.S.(C). etc.. cardiac surgeon, Safarjang Hospital, 'l'\e\\' Delhi, l rnor6, India. I has also IJce11 supportt"l J,_, thl' ,xpcri111c11ta: j production of rnesotheliorna k \\';ig!lfT ( rc/i2). However, its exact :etiok.gy. i,; "till 1.rnsettkd. I as it i,; :ilso fou!l(I in 11011-indn'-trial ,1nrk('fS. f Fnrthern1m1, its lliirphr1ln~: i,. ,fill Jl1 t 11 ell I nndnstood. and ib l1i~tn11;1t l 1ril11c:ic:11 pict i:re t and biological licli;11ionr h;t\'t l('Jl 1bc :'uh- jects "f co11trn1er'\'. Tl]('n i-. ll<'< c;ati,factnry ( treatment for malignant me~nlllf'linrna. ~ This presentati,IJl is based 1;11 the experi- ence in the management of fi,e i'a'e' rif rnc,nthdioma lielonging to the 11nn-i11dn-tria1 rural cnnm111nities of T11di:1. trcat('d :1: the \\.:1nless Hospiial. '\Iiraj :\f('(lical Co11e~t'. \firaj. Maharashtra. bet\1ecn Jannan 1ri;-1 and '\forch 1976. and aims at elucidating i1 s ;etiolog\ and patholog.y ancl ttpd:iting it, ther;q>1 :1ml prognosis. CLDIICAL REcnirn~ CASE r.--A J,)-year-old agriculturjst engaged in intensive sugar-cane fanning was lios;italizPd with principal complaints of chest pai11 and dyspncra of four months' duration. On examination his chest was uormal in shape and size. There was a dull percussion nole in the left lower and mi<ldle lung fields, with markedly diminished breath sounds. Skiagrams of the chest revealed a large m~ss continuous with the cardiac shado\\' and occup,ing most of th(' left hemithorax. Thoracocrnt''i' and en<ln;copy were unproductive. 218 J:t;li 1.'111:ti! 1.11 !11 l'\l't: \<J'i'"' t ~ r; jH, \];ti -<t' 1.:t 11 ll 01' t l'nti: Her\ CUl\t Oi11.-; l"l'l 11 111 at\<1 n, ,1 rha t L( \1' >.!ESOTHELJOi\1.\ J:\ 1:\'I>L\ a homogeneous opacity of the entire left hemitliorax with shift of the mediastinum to the right (Figure 2). The pleural fluid contained no organisms or malignant cells. I l ospital course.- The patient under\\'cnt left tlwracotomy. Thnc \\'a.; dc11se adhl'sion bet \\'CC!l the ltmg and the pkma, which was markedly thickened (25crn to 1ocm), wid11lar am] firm, an~I gave the <ljJJtaraIHT of diffm:t ltm10ur~ encas;"~ tll<: collapst"d lung. This was mon- pronounce1! in "tlH' lower part ni the thoracic c;nity and mTr the diaphragm and the mediastinum. TJ;,. tumCJur ma'" extended to the ll\S FT \I.If \: appearance. with areas oi necrosis. The left Inns with the main bronchi measured I I crn :< 7 5 cm x i tr. cm. Small and large gre,ish-\\hite nodules were ."i\: present all over its surface: Its rm surface showed ;1l one greyish-whiie oral grn111h 11 itL central rnr:1";, ti 1nea'.'llri11c- ..! s cr11 x 2 etn, ,,it!! ~{'\Tral .'-irnil:tr ana .. 'l of 'J11;t!ln .si.1L 1\11otll('r area "f tlte Ii111'..! ,Jio11d In spn:td u/ tl1L llllll()tlr fnnn tlit ,11rr;1n t(' u:t 0\ t depth of the lung along the b,,,nchns. ~ficro scopically, the scctiom of the pleural mass<-' 'howe-.1 ~' '" '-i tumour rPJls arranged in tubular fa,ohi,,_ ur iorma- '\ tion uf papillary proce,ses on the cor<-s oi r1,1rnccti1c 11: l tis.sue. The tumour cells were cul1oidal. columnar "' or polyhedral in shape, and rnntained hyperc1:ro- ('\ t rnatic uuclei (Fipire 3). :iran_1 acini c"ntained 11 hyali11e t'tJ.sinophilic material. TJ,e qn,ma ni the l ~: I t11111tiur con,istcd o[ abundant ace"1ul:tr f;l1n1' t1ssue. 1: The sections from tht. ltm<!' .sht,1;erl metastatic ! ('( i d('p<lsit~. 'Tlll.r..l dcpn:--it-.: \\-1.~rt \nn cirlt~rn:'crilil'/ :u l .t.1 ! '" I 1 FH:n{E 2: Case 3; pCJstcrn-anterior skiagram of the chest showing cornpktt opaciticalion of the leit lwmithorax and shift of the media,tin11111 to the right. right side across tlw r\'lrosternal ,;pace and completely filled the canliophrenic and ,ostophrenir angles. Subtotal rcn1<J\al uf the pleural mass (ap]iroximatcl} 2,:;no .~rn) was doll<' to ire< the ltrn.v, li11t f]I(' cl1-c.. rti.-.t1<,J ltJllg Ltikd t" c;pand. It appeared to lie i1;,-.1h vd I" tlic tumonr. ;rnd there was extt:nsiYe air leak. net:,,s,;itatinr! ldt pmnmo- 1wclo1ny. lli':'\ pust11pc:r;1tiv< cour:--c \\a..; stonny. S11h-,eqt1cntly lie rct'l"ind a r<i11r'" ui radiutlierapy and chemotherapy (t"ycloplio.,pl1amide) a11d resJH>nded well. He is still dui!lg well si1Ke Iii.' s1;rger) i11 J1111e I<)/5. JTurhid a11alo11n.~- Tl1e sprcinwn consisted of big tu1no11r n1ass(:-:. \\'(iliin- 2.;.00 tln1, The 1argc"t piece measured 12 en 1 ,. 7 cm :< J cm and was com posed of seYeral small a11d large 11od11le'<. Tlw cut ,urfacc ,;!rowed a g-~,., ;,i. 11-bite ho111c><Tr11rn1!s F1c1t1n: 3: Case 3; phutomicro;;r;:iJJh of 'ection from 1hc: tumour mass -.rwv;ing tuliulopapillary type of llllSuthclioma (I1;c1n;1tox,!i11 and Cu>in. x 350) and were separated from the Jun;.; p:tn 11chyrna f,y a laver of lymphocytic tissue. Tl.e bronchi were rnirmal. There was no evidence of a>Lesto:< rodies or aslicsttJs-likc bodies. ;\ dia~nmi, of diffuse metastasiziug rnrsothelioma of tl;c rdcura (tubulopapillary t~JH') was macle. I [ I I f I ! i J I I I I l I ! \ III ti I tl d .\ iT AT.Tr ~!ESOTHE!.IO'.'d \ L\ J:'\llf.\ ~TUDY ;IJ S. G. ery and JI edical ,'[' ,, ri Illt'lllal ( 1<}62). lllSC\t\ed, 1rorkers. !Hit well pkt ure 11ic suhi-J:1dory experi .. < 1f ll JC~o ial rural \Vanless :\Tira j. ..J 1\farch logy and 'PY and ' . 1..: . _, '-..1.'' .1.~agcd in :ized with dysprnra i..-i his chest as a dull il<lle lung i. r:<Csouncl~ :.1.. tnas~ l)i.'C~tpying 1it"s1s and ,; !losf'ilal cours,-.-At partly solid and partl opc_ratioll a huge mass, continuous wit!: the y cystic, was io11nd. It pericardium and occupied was I!.\~ l:T Al.II ;.1'urlrlal1c1gacnd.:ai1s1, stwraitnhdsa wwith interlaciris lnm<llcs and, in eaxi ctehpet leinft osindee aorietahe'vchheePset. iltt was well ..:ncapsumlatocsdt cells showed hypcrclin eosi110pliilhicorcleydtopplaatstmernw. itThheelotungmour li!'Per lobe of the left 0i the uericanliurn lung. was adherent The entire left to the aspect fcraLio11 mof1atwiccs1<11t1licdkii.at l.nceplllsacefsortmheinre was a praotleid- l''ratnl a<:tua\ in t!ic ma'' appeared of "hirl1 i11ro\ycc] and incortl1e major pa d)Jagtrtnccrnrati(uF1i1g1oirfr :iIt)r.ornAarleacs of necrosigs aandglamnydxuoliadr ly lud;;cd uppc1 !uh 11;,. ii11ntitmhaete]p~eriacdarhdeirae! rarity. rt The was left l r:1ti"n 111 t!H: of prilrnonar.1 al1co ells were also tisstlC'. with tnmour seen. giant Infilcells nt to the tmnour !i !rJci1.;c1aolpatals1ol1l estu, whaos<li1cs1reosernta. ,1L>ncnslgos-sliekcetiobnosdidesid 11r1t 1licl i<Jlll:t oc~ical diagnosis of ( t111.11lopapillary 1ariety malignant . J\ nwso- :1 11as 111adc ( 1,;1: ian1ily ,, ,\ cnga,~cd ;;5-)0 ar-old liou;nviie in s11~ar-cane in a rnral J1ilalizcd with cxertiunal clyspmcafanan11iidlt:,c.:1'Cwllailslg- Jr1iosse- nxlfiae11tcc1p1i1,opccrlael\1orcf loifamOllpl.'lymsios lltdlui'r,;i11dgur!ahtiisonp. erSlic haJ the 1i11ati<'ll ht'\. there w:;': a Tl1c tracl1ea lJlllgc was in the iud. On left side o[ .\o :qiical iinp11lsc i111p:1in"<l 1Jtn11s,irn1 w"a"stepalpahsl!ei.i f t c dT hteor et h e~a.roi g ha nt . s1Amtls in tli~ l1111u part witl1 tlimiuishcd of the left side breath of the 1d1l1l'as'.t' . inStkliieaglrnawmesr pPafrt tohfc tilclh' elsetft rleuvnegalfeideld.a ilosj'ita! "";1r.,,. \1 exploration a large large nHa-.t1:111,!..! ,.;o psterior and cn1 :< r_; c111 lu11T arC'as I!) of c111, a11(l t11111our, occupyiIJ.~ the 11as fut111. '!'lie pari\tal the left pleura was thoracic inYoh-ed cavity, in the t'1"11"1t1!i1a<1,1so,1ur.\1 Tl1li1cleir"w1a1sasc;"is"ilycitef-rscted\\'allily icnxvtorJaypelcm11ral dis- l11ng, r was li11l thr adherrnt to 11ppcr Johe the- lower appcarer lohc cnl. The of tht- left ll;J' resC'ct<'d in c"ntirl!1itv alom; l free. The tumour with the ldt 1.iwcr rlco1li1e1.ai1wSld1e 11 <ll'Ilia1skincaen he1rI11oZp-1l'tr:anttfi;inl n ricnroFveehr;v11aarnyd 10h7a4s. .1/nrlid 1 )ar'-'.(' tlllllOlJ!1r111,l!<0>11C1.tvn. TLC' -pccirnrn l 5 Clll X rnncisted of a l1111cr 111 it. lobe ar11! 1art 11f tl"' lt hat{ a 1-;1ricgatcd I.'j 011, with parietal ]>le11ra tJW Jcft attadwd ir11n1rrilinl 1iP1is nnalcd t'.\Cc)lt in appearance. It was one area ..lvfkroscopic wl:ll sec- nlls n 11 itli a 111wlci ltllll<llJr 111iich c-on1pose<l of spindlt harl pointer] ends. sl1ape<l 11;:1o1:i1n1<!<the' 1l11'aais11e t1u; rnpohuot<nnicrn:~raph of :..;1cti<;JJ 11 i11 :in ianr!rcarnlgatc"ilnl g ini11aan1wwhr.or/l\crfl111pattern :ind The C'ells in pbcPs 1hclio111a r (kt'lllatoxylin n1a ... s slio wi 11g tl1C')0and eosin. x 350). !1i;.t-'vnrJcO;rtrlhian'-'.'i<c"<'ail1. 1Tal'1ta' n'<1tio11-; ,!"]andubr structures fror11 tlie Jung sl1nwcd ,1 1ra' strctdi1d "' n sinelcitltiroanlis11i,h;. Tlw1 11c1Td farnt'l'asfrwomiil1 ltilnllfllOatmlrm. .Aalto>~n. rtlell ... ::,;1prcsstd and ',; the tumour it, collapsed. wFloiirlccotlm1eplle<tren:erxltoirbpeatwioans l1i,!olugi1:al11wdiea1.fQnnoosi't'\'iodft'ilC1.<C1' Jigo1f1 am>chscstos hOflies. Aie ',,tire Id! 11ith aspcd nf a g-ood the surgical margin, the in:ule. othelioma 1n1:; ::..~:qntcint1;i,ntyil ldt with up1cr Jolie pehraidcarttolimbne, tlw tumnm. ~li'c slaecfrtifipcherd('niinc :rratirc 1ours_1 was unc1 e11ll.11!,. patient's an<l he postlias (','."r- ,\. ad111itkil t<1 \ .:!/-\c:1r-l)ld s11}..'.ar-ca11e lrospit;d 11itl1 cn111pl:iin farnier \vas 1w, ldt sidl'd clit'st 1ur ,,i~lttcrn mont i:iin :u1d ts uf hreatl11cssa11.ircxia, dating hack :.i.l\lJO,1triltlli'dd \I,1T1ll11,uJIoJCm("y.-\-1T1SlieSt1q::ery lll _l;rn11ary J074. lLi;r"larlil;"1"ss had hhsc.o:1\Jt1r tl1llp'liltcim;e;pvnefre.atlHmis<>irm, his ,':~,-.-,:"i.z;:'.,.:re~\1i:-i,thh S(1ft tissue spcci111cn n1ass, ;;o c1n ro1histed x :!5 cu1 x c,f a 20 cin l1ad rre(p'Ccalllrcr-cdnt tl1poltr-a1cllo'a<l crc1ftfl1''l1'Ssi,,n:L,t for wl1ide1 hah<e1 alilasdo :~:'a,Jnlitl to i1 11t11rLt ttloaf rt-hareiegl:ulingtl aanpdpeaprericardi1;ni a11d :tl'c. rccil"r<l ,11n:q1y. apparc11tl1 " course itl1 a11otlier instillliion, of antitubercnlois ;ma' .::.:'.~;,,.ir area-. altt.rnating 11itl1 n,crotic lt 11as well rirc11m ance, \11tl1 and l1a:mnr- ,;t\1n i11dicaliotJ. ,i,;;11! tn n11 11 c\al0l111it11aa1li1o1n Jt.1awctcrtiroa!dolgl'ilclalwor ''.(l<'il ' :1rai11 11ikt r it \<\J><; adltr-rl'llt t,,sCt1'r1il"dlu.rige-.xc'Mepitrrnin 11cr the tJ!a1L.JL ri.lil. Tl1c rcsniralon 1cs.trirltl. :11:rl llH'rl' as 1nff1"tnll'1Ls ~, l 1l0 ( 1.ac mpo,c1l oi >Jiwlk .;!Japed cc]!,, 11t"""' (Jtl 1!11.. '.\ \r( aJi...;cnl kft-<.;id(' in tlri, uf tl:t llw-1. \\';lS sionv r111ll- nrt'atl1 '-ldllJd"- :1r::1. Cl1r,st "ki:n~r:-llil'-' rt'\"(':11("1 . --------- ------- -------- --~---- ;dESOTHELIO~L\ !:\ l.'\!JL\ l~ASE 4.-A 54-year--old sugar-cane farmer was transferred to the cardiothoracic unit for exploratory scirgery ior a recurrent and persistent right-sided pleural effusion. His symptoms had commenced iirce month> previously, when he developed right sided chest pain and breathlessness. He was treated IJ1 his physician 11 ith antituberculosis drugs, with-otll any appar1::.1lt benefit. On examination, the Il'"'iir;t1(1ry lll(J\TllH'tll-> were re"trictcll on the right,idc, and a dull pnc:i,;sion note 11ith ,;uccussion >rrlash was abo 1,res(nt. Breath sounds were absent in tht right Jun!-'. freld. He had several thoracol'<Lt<'"'' ht:fore anti after admission. The plenral ctTwi"n rta1rpearcd rapidly each time. The ileural fltwl cuntainc<I no organisms or malignant cells. :-:k1;i c.ran 1- u i t ltc chl'st nnail'd a ri:-clit-silkd 1 .tt:.11~;1! dtnion. Skiac::rams taken following thoraco- ccnll''i-- sltu11l'd obliteration of the can!iophrenic ;111 .~k and thickenin~ of tit<: rig-ht cardiac border, ;,nd tltc radiolo:rical :-ign of ;;calloping was present ,,1 c: tl:c rli;q.liragm;1tic and media,timl pleura. I i.\S FT .\LI l were ,, u1 ,,,Tr the lung .,;urfacc and the parietal pltura. ;\ rounded dlpo,;it, 3 <"m :.! cm in size, was presrnt 011 tl1e medial aswct oi the right upper lobe 11<:ar the fiss11re. ( )ne large deposit was found l>ll tlte cl1<st wall, involvirn'. the latissimus clorsi muscle at the site ot a prcvio11s tltoracoccnt.:sis. '.\lultiplc biopsy specimens W<TC obtained from the l'ariom ,itcs. His postr,pcratin cuur<e was unremarkable I le has received a course of radiotherapy and :lll1nutltnapy (cyrl1>pl1os1ha11tid<). l If' has remained \\dl ~ince hi-.: surgery in .r\t16l1St H>/S. '. i ' on ry !'.l, ,,. a ,\ere ;rlits (i use ,qJo- F11;11<i: ..i: Case ..i; pltotomicro;"raph of section 1:1::.1~,1\1l:tdhien11:atumI olt1;t1'1r11ast<h1o,ywliinng;t11tdihrtnut-t-:n; 1, type of 3.:;o). / f, \'f'llai lo11r,il'. -Tl1e 11atient undcrwult right '"''' '"otum). The pleural ca\ity contained about ; uu' ml d stra1' -rolottrcd fhtid. Tltc-n was a lt!il'' and n(Jdular gnJ\\th _,,[ the n~cdiastiual and .li:qlna'..'.rnatic pkura._ tlw th1ckn(;s: .01 wl11ch van~d ;,.l,,11 one :o 1110 ut1tllnt:tn-, ..\luaq11c ;;:n:ill depostb 1"'1Ltih'.1: 5: ( -a~l 5; 110'-t1 1o;u1trrior :)kia,:._o;L1n1 ol th< dit"t sl1owin;4 ntas,1\1 1,Jcural 1:Hn,ion ''" thi: t ic;ht ;;irle . .1/urhd una.'vJJ/\'. Till' biupc.y spuirnc:n- wtte :...:rlyi~l1 \\hi1e and "'(if-t. \\i1._1osco; ically, tlit >t'Cliv;1-:. ~Lu.\\ t1_l a ttn1101ir co1n10--cd of dcnsv colb.1..~env_is ti~:--111 u1rlil~:lng ~t:\ L'r;d cli1:-.tlr-., of tun1our cells ( l'i)..'." :c -1). In places. i ucccl lol kctio?ts uf chronic J1lt1a111lll<ltn1 \' 1Tlh \\Cf(' Sl'.fli. r!'hc findings \VCtT ,iuular :n ;,]! th '-lll'cimc'tts. The "fH'Cirncn from t1lc d>c:st w;tli dcpo,it \\as grcyish whitl' anrl horno- :.':t'lll:O\h. ''vl icrm.-upic -,cctions from the deposit ,,\""1Td tl1ick fiJ,rn11- t;,suc ,,itl1 sb~letal mnsck, There \Yt_Tc areas qf grCll!11lation tissne with con- f'l'Stcd capillaries and lyrnpltocytic infiltration. There 11cr< rnanv c1-stic area' linvd by singk c"ll and nmltipk n:ll ];~yen, wit!. hypnd1romat ic nnclci witl> pkorno1 phi;.rn. Their cytoplasm w:is '<anty and l'Oslnophilic. They wvr< n1ainly present in tl1c tibrous tissue, hut had i111a<k<l tht' muscle in many place;;. :\ _l~'.stological ~!iat!nosis ,, f rnalignant mesntlll' li11t 11a l h1>rt1th t 1p .1 was rnad,._ (. \~L \ 1<1,\l:tr<>l<l 11ta!e rl>enti't in a 'lLar l;.\("l(lj \ 1\t1- J,,",,l'it:dizcd t\lth a Cllllcd1 of J~ ,1;~1s' . : -~I .\1F:-'.r!'IJ11:1 /r '\i \ ! /\ d111;t1io11 ~t11d \.1c!{)./,~ li:ul aJn,~Hh n~ci\td r(.J if:rc,' li.;l~ lll' d.' :-.pncea v~(lr-..(1H d :--(1,i!C ,,1ifsi(!:. trlat111u1l, l11Jf Iii ;tlii h1 k1 .!1)1wd a ri.:.:l:t "i1kd pkur;il cfr11:--in11. ( )11 ( \an1i1',lliu11. 11ie tntire right lln:cc11nlllth1nr'(;li\:J\11d~\.\(!(.'.;h1d-:t!I! .-i:\lVa:i!-/;1r;1ii;l-d.,,trtnf\caokrd di1r1ini:--lwd :t !11a;;:::~1\c r1,:.:.ht--..:idc 1l p!t 11r:ii ~ tn(c'--i~ f(;llO\\ in:..: 1 /i Li:~ . ! l - H1J. ( 1:;'....'.\lrl _; }. 1i(1s1i~al ;ldtnis~iu11 T i lo y r : ' . : ' r ) - 11 1 "( li;<:'11101 rl;.i:i, lluiI. 11\11 ilH lc!dt.tl plc11r;.I > ~t'...!a111 Ji:t('<' :111d Ldr lie rvr111ircd daily !;!fl/1i11.!_ 'flw or 111a1i~nzu1t r:tl Cf'1L...;_ t111id C!lf1t.ti111.!l J1() eir~~a11i..::1ns .~~ ...... Ill ~. .,., .. ~.,,. - ~ ... Ii I>\:-; i .T \i !: 1-l1;i1JJi<~l'. !iis l"l":--J1<i11-..1.._ to !Iii-- 11_:::.i111L!J \\;l.-: 10D\ J ii_-., dy:--p11n2a co1!li1111t'd to i1wr1;1-..c c"11dition ,tarted to dderi,,rat>C. ati.J J.i~ .\leanw 1 ;u1cra1 de\ l'.JOIJC'd .-..c\-craI nodu1cs in the- ;.;cal;1, fJIJe hile, ii,, t1i wbid; .1. as excisld ior l1iop~y, \\IiicJ; pro\cd lt tn iic :i !r11,1:qI1Jr.tH1a:slsitteatnic1f11alsi1i1se]s'o(J-ilrl'1lr:n(niliitotnemdsa.. t(.-l\s ith-aen"also<p!.i'.tOai!il~ "rJoitnh: Morbid >-lto\\'c<l a a11t1/0J11y.-- ...\[icn"'"l';cally tLc sntion; tu111011r consi:-.tin.'..!." of 1 =sheer;; and .~Tour~ oi epithelial cclls ('_l'toplas111 1 \\hich wl1i,h were \\as gra1111Jar pol_1 and ~rn1al \\it11 ;;c:11:1> er sinopbilic "iii> 1,:. ,/ear margin,, The nuclei in tl1c m:tjority of rel'.< 11c11 larg1 :111d ttecttpied 1110<( ui They Wt'rt' 1c,ic11lar with pr tlic n.:11 sp:1c' 1 .-<orne ana,, the cells \\'eH un1ill('Jl( 1111ckoli. !n pler,1:1or11hc "ith lnyr- .-l1ro111atil' llll('!t i. an<l nuckoli could also lie ca'ilr 111ad" 0111. \!;1111 i'e11 t1m1nur '.'.iat;t almorinal ,,II.' 11nc mitotic fl(ur<<; <C'C'IL .\r.-a:; of 11ith " ncrro>t' a11d h;l1110rrl;ag, in the <mroundin1.; area' \1ne alst1 prcscnt. tumour Fibrous tissur nlls. li111 in areas separatcrl where tlw thr .:croup< ot qiithelial ccil> \\'<'re typic:tll_1 11111lig11ant, !hr strnmal cp]J, ll't're al;" 1naligna11i, rr-<rmhlin.12 patfiulo~'.i1:;d diagno-.i-. <arrn111a ( Figu:t (j). df n1a1i.~11;ii;t t11l''Otl .\ l1i;tJ: lti111orpliic or 111i\cd type 11as made. 1 clii1m:1 O! . \l1cro<c11pit cxa111inatirn1 nl the mct:1-<tatic depn,JI i11 tl1" calp n 11;1kd a t1n111>111 ma-< c"11':t'd /.y 1nn11;t1 ...;kin. The t11111n11r \\;1..; rn .. ~in:~ thl' l1a-.;d l't'll l;111r. and i11 mall\ p/:1cis it had dc-t1t1\(',J it t111no1ir co11sisted t,f spindle nlls \\'itl1 1ck011 The ti;J1, 1itTil1r<1111:1lic ll!H'ili. 1nrp1iic \Lin,, t1111H>t~~- ....:i:un l.l \] ... 1{1'11\i.kc111T1l11~\rriat1l;1c~rJlr\J\ll1;'11l-.-.l.._t.\.,i]11'~f\:L'1()el1dl1'it-1'..1lip'-r.i1;~l11-':.ih1:-r:il<TiJl"Jli..1:1(JTJ1 1{l.1k'tyr:t'l\:\-h''ei.-..n.:.''tin~r1..:.l:tcCharn1tl)l1ot1-r1:t...1:itcl1a::r1: F1cnn (1: Case s: photurnirrograph oi section from tht tumour ,;l;owing bimorphic t11w of 111c,otliclie1ma (h;c111at<h1/in a11d tosin, . .fk1_o). llospital co11r.iC. In vie" mulation ,,j pleural fl11id, 01 liK lie ra]>id rcacn1 exploratory thoracolon1y. Tlic 11ndcrwent entire ple11ral right spar(' was filled collapsed with kt111orrl1agic fluid. The hmg appeand and hound do11 n hy fihrinons al!d deposits on its suri;1ce. A hard and nodular tt1111our tu111011r mass was and lower present parietal 01er large areas of the posterior pleura and in the angle ht'! the diaphragm and the p<htcrinr chest W('en wall. I1m1unerabk small of the visceral and 1l1111011r parietal dept" its 011 pleura were all aspect' seen, more so in tl1e lowfr portion of the cl1t<;f calih. \Vitli the lie diagnosis of was treated inoperalilc di ffri-c 1nc:<othclinma, 111 radiotl1,-i-;ipv ancl nTl<>phos- 222 Dr:'tT~s1n~ \Tcs(itlll'li"tll;1 1." :1 rar(' t1111H>J1r. an<l it' frcq11ct1th 1111p1Ttlict:i11lc- clinic:il lwli:11iti\lr tJt:t kcs it a cllrnplc" t hl'rapclH ic prnlilrm. Tlll:wi<soicrtsltl'r.!~Ti<tllhljal s Cl<l('1c1111sisdbi,nidfcdsoil1i1tat"ry11.111''lw~nn11i1gp-;n;'.' t11t1tour." ll'hich arc sun~icalh- rcsc1t:thk an<l earn a gnrd proi:nnsi.,: wherc;is the second group comprises diffuse "111alig11ant'' tu11101tr' which spread localh in a prngressin 111a11ncr. c:1rn an 11nfan1u-ralilc prognosis a11d encl iPaat1a1llh~-nn.1111q(l)e5s)s. tha11 a year ( ('r:;clJel and Sill' of Origin The pleura is the com111onest sik <tf origin !Ji this tumour. hut it can als(J .origin:1te. though less frequently. from the peritoneum. pericardium and other serous membranes. In this series, four patients ha<l pleural mesotheliomas and one ha<l a pcricanlial mcsothelioma. From our redcw of the literature, it would srem that there has l>C'en much .\1sr. 0:.Z. _I. St:Hc., \'1iL. -tli --- Xo. 3, A1cisT, 1076 Ct lllf ttc j, and n;, \'aria!,:'. m:tto11-. pre,-;1ili CPpt (nc!ot 1 t R,,Jicn . !.('Ji('\ f i 11~ ti J an n< l :-.1111 re< Ral1i11 natetl and i 1 - (), f Tl it lar~-tl\ Toli11-1, htliCI t rtact j, 1 111ator\ Cl'rf ;1;1, Pttl111 c1 ( \ \' ;1 ~- i Stlik,, prnd11t ashc.(\\';1'.'.' pati<-11' ('"pt c-1 lhl' !'ti p:tt Hr 1ng CI and t L ( in<li.~ pati<rt Thi~ ( i 11 t' ". the " all it tJ rct n:11 prorrdrird a 11<1 < say :1' tlii. i" CC'S< pntr\\; asli{"' Lll )Of. :ral he ;ich e a Wll- the lUll:'. Hl})S .t11ty Ai(Ji .:ells acc. In [Cr- l'iJy h a '( 1 ..:is also nf ,ells also i-;toa oi un~it l h 'nil The :pliic c<'lls d in ;.:iral th(' its 11 l\lf ;Je111. >llJlS. :i~n" an(l cond 1n11 r~ :1ner. end arn\ rigin mate. l<'lltn. In <nral mlial i1cra11mch l ;dESUlllEl.10~1.\ I\: l~IJI.\ 1coninsion a\1(1 controYersy regarding the ongm and nature of this lesion. Its histological rari;ii>ilih from a sarcomatous. to a carcinomatous ;ppea.rance has also contributed to the preyailing confu~ion. The time-honoured concept that tl1is tumour ongmates as an endotlieli1J111a kt' heen (fo;canled. Howeyer, Roh\'rt~o11 \ 1().2 1, and V/illis ( 1q(i/) did not IJl'linT tlial tlwsc lt1111ours existed. a11d accordim; to them. th\'y rl'pre~ented 111eiastases frum an occult, 1111recng11ize(l or l:itl'llt pri!ll;iry "'ttr('<'. p11~sihly in the lung. Klc11qwrn and Rabin 1 l ).)I\ felt that the -.nlitary h'])(' originated fr, >111 the 'tthpleural c<>1111ec1 in' tissue ::nd it- ,Jiffu,e 1:1rid1 frn111 th(' p!t'tll'al -.ttrface. Occ11/iatio11ul l:xf'osur". _Etiulo1n ,111d llisfoqi'n,sis The :etiulog,. of rnc,;ntlilli<'III:c rl'rna111s bn.~eh' unsettkd. TTn1q1Lr. 1fr111111 a11d john~rn1 1 l'1,; 1 1 :,llC\ rn:u11 11tlicr 111Jrkcb i1clicnd :l1at it rc,ultl'd ir"111 tl1l' lii-ot, ilo~ical j n:ic1i"11 ~no11dan \,, tlw irrit:tlion a11d infla111111alon pnwcs.; ill th(' pleura. Tlii, concept . '"'rtai11h sunport' th(' cli11i, :ti :1,;,;11ciati1n1 oi t p1~l111011an a,;] w-.t1 ,,i, ll'it 1t Ill<':i it lwlio111a I 1\\.ag11n <I a/ii. 111)11: II.i11rili;11H'. 1q111: } Selikuff d alii. T<}' '-\ '. a,; 'lue,; the experimental; :I:, production 1Jf 111ootlwliorna h1 i11-.tillation of :1,]w-.l<h d11sh i11'.11 the pleural ,-a1itv If rats 1\\'agner. l</)21 B11t ill rnnw of (J\tr fj\.._' pJtients 11as tlwn a111 ckllKt' of occupational l e:-.:p<hlll'l' t11 a.;Ll.;to,;. a-. ti1e\ all l1l'l<ll1gt'd to l tlic rnr:tl c11rnmu11it_1. l1a1i11g a,;-<1ciatio11 with ., . trade~. ;ugar-c;\11(' farrni11,c'. and rcJat,d Fonr 11a1i,11b lwl()11g1d 111 till' 11!111-iwlu,;trial farni- ine: C(lllll11Ullity. 1.n.L!:tged in 'ugar-e<lll(' fan11i11g :n;cl tlit 111;1ki11g nf jaggl'n \ gur) atHl 111nlassc-; 1 1i111lig('11on,; sugar-cane pr()(lttcb). Tl1e fifth 'l:. patient \\'as a clll'111ist in a ]"cal sugar facton. Thi,; oi1,t'l'\'atio11 prn\'ir\c,; on(' more possibility in the unsettled ;vtiukigy of thi,; lesion. \Vhethcr . the association of su,~ar-cane farming and . a11ied trades has atff <etiological !waring or not I', remaiih \\f-ide Ojc:1 ill1: sp<:,ubtion. I11 the I process n prqJan11g pg-gery and 11101asses. dried arnl crushd sug:1r-canl' is n~ed as fuel. '.. :n<l emits irrita7i11g fun1c'' It i~ diflirnlt to <ti' at this stage ii these' furnl's could irritat<' '1S th~ plrnra arnl promot1 an inflamtnat"ry prn- cr:is. Hn11(-ver. -inn' 11w~ntlwlin111a has lwe11 .:. . 1,1.,1,lt11'cd e~pni111cmalh h1 i11.;1 ill:tt ion nf ;1,]lcs\<l,; r111~t i1Ho tli p!C'ural ~]'<kl' 11f rah \!:" ~'/ _l. S!i,:, \,1 jll l: .\..(1 3. \!,[",,\ [.)~{\ Ji\S L'I .\I.II ( \Vagncr, 1<)62) and li_v the use of diatornaccuus earth a11cl polyurethane ( Hueper, 1q0.1.). it is quite possible that the dust or fumes from the linrnt or hurning sugar-cane could al;;o prod\lcc irriiatio11 and an inflam111atory prnce~-.; i11 the pleura and re:;ult in the prodnctio11 of a 1rns(Jthclio111a. This ccrt<ti11lv calls for a critical a11ah~is nf all ca:;cs reporte~l fro111 tli<' s11gar-ca11<' gro\\'i11g are;1s and 1wcessitatc~ a looko11t for am Jl('W case coming from these area.'. before one ,:a11 blame sugar-c:rnc a:- rift(' of the aliolo~ical factors. Abo. so11ie e::pnilllental worl.: it;, lahorat<iry ;111i111als 111:1v he essential to prov<' !hi~ p1ii11t. [11 this rcg;inl, we ha 1t n:1iewC'd s<1c11 autop.-;y cases, ii vc r<'jl<1r\l'd Iii .\ibt t'i ,ifii ( l'J7-1l and l111J Ii~ 1' shir,agar et a/ii I 1ci;1 i. all(l three doc11111t11krl cast's rcprirtl'd liy Reddy ( 1q~()1, h'.ldd1 ,/ alii I l<J;-.) J. :twl Ch:t1Hlmkar d 1.li, ( 1C)7~'\. and fo1111d that :ill 1hf'~f' c;i,s1,; aLo ca1:1c f1.,.rn the 11t111-i11.1t1,:ri:il rttral co1111111111i1\_ 11111111-cr. ii is rnrt ck:tr f1'<,111 till'. casl' his101-:b \\'lwtlwr or 11ot ;111\ 11i 1Jw~e pa1i"nh 11ac: ass"ciatl'd \l'ith ,;1war-1:1111 f:tn11ing, hut [.,10 ;-ttttop:-:y ca-..rs rl'ported by l(shir~agar ct ~:/ii ( 1q;::-r '1 ;,nd 11w c:tsl "f Cli:111dt1rkar ct ali; ( H1;-_;') did cn11w fnn11 \f;il1:1rasl1tra, a lielt 11i i11tcn-;i1< sugar-ca1H farn1i11.L'; i11 lndia. T'.1is oli~l't'\'ati1111. :dong 11-itli our finding in f' 1e patie!lt:; i11ti111atl'h ;1'i,<1ciat(d "ii11 sug;ir-canc farn1i11g 11r a11 allil'il tr:tdc. iwlicat<'s that tlwrc 11n1.-t ill a factor i11 tlil' 11011-indu.;lrial r11ral arl':ts L'<tl11lr!tt1 ll'i1h fanning n .;pcn1sihlc f"r i11duci11g n1csutlll'li()111:1 i11 the sanw 11t1 as aslil'St<h is. Fnrthn i11nstigati011s are required tr, pro'" this P"i ni. Tlic histo1Jatliological 1ariatio11 of 11H''iO tliclio111a can lw l''- plaitwd :ct iolngical1_1 or cntl1nnlngicalh. Th(' plcmal r;iYity is li1w<1 liy so111atopkura a11d s]'Ja1,cJ111ople11ra, hr.th of 111iich dc\'llop fro111 tlH' 1111s1Hlerti1, anrl thercf1n l1otli <'pithdial a11d <'11<l<>t11elial strncture.; t .iuld d<'\'l'lnp either ~cpar:ttdy or in C(l111liillatio11 ll'rsdtel and l'aul~ntl. 11/i;'1. l'tili;,i11g th< ti~~ll(' c1tlt11re t<'chniqiw of >.ra~i11Hi11, St1ut a11d >.f11rra1 ( 1q.p \ and Sa110 ('/ alii ( !<))().) co11- lirnwil till' 11H'<<1theliai origin of these tu111()\tr~. and St"l!t and Murray (1<.112) de111n11str;1krl tlw tr;rn~ion11ati<111 "i .111t"><>1lll'lial ti~-11e,; i11!f; fi],n;]iJ:bl~ with t]l(' 1:n1d11ctio11 of c1ilb'.,!W1\b 111atcri:tl. The1 :ils< ,]11iwC'd tl1a: a lwrig11 1111'~r11lwli<n11a -Clll p1od11c1 <11i1\1('li;tl relL' i11 1i".11c n1lt11n. :-:a11" 11 ,i/ii i 11,;:i 1 d";11111h1r;t111l .vi E5'< lTHEI.10.\J .\ I.\ I.\ I >I.\ that the rnalig11a11t Yaridy of 11iesothelio111a can also produce epithl'!iai cells which ordinarily are not seen in tile srctions. Later, Manguikian and Prior ( I<J(>3) confirmed that tlic reaction of mesotheli um to injury cou!rl he in the form of cuboiclal. c<ilunmar and epithelial patterns accompanied by papillary process('S. Thus the mnltipotcntiality of the tnmom is demonstrated on a cellular hasi~ and i~ confmned !Jy its clinical J.eha\'iom. It h:is hc<'n sern that many of the lwnign mesotlwliornas ;.ppear malignant histnlfJgkalh. while '()me nf the clinically malignant nws(Jilll'liomas haw ;1 lwnign histoJi,~ical app(':Lr:mce ( Pr:o;clwl ;rnd Pai ti _.;on. rcifis). Sy111f'I0171'! / 1JT0.<J.\' The classical presenting frature~ nf a pati('nt \\ ith rnesotheliorna art c]w-;t pain, lin'athle~s lll'ss and congl1, !)111 p;tli('n(S rna1 abo h:ffc less freq11l'nt complaints such as loss of weiRht, weak11ess. frvtT, alid11111i11al .;1rnpto111 .;, chills. q11satif>11 nf fullncss a11d ti.t.:l1tness in thl' cl1c:;1. awl hackachr. Tn the pa Iienb descrihed in this report, breathlessness and Joss of weight (all five patients) and chest pain (four patients) were the most frequent complaints. However, fever \dth chills and ha:moptysis were present in one patient (Case 2). Physical examination of a patient with diffuse nwsotlwlioma 11sualh- re\'eals signs of pleural effusion or a large i11trathorac_ic or mediasti11al mass. Occasionally. clubbing of the fingers and features of ost('()arthropathy may be present. In this report. three patients had massive pleural effusions (Cases 3, t and 5). which reappeared immedia!l'ly afte1 thoraco- ccntesis. The pleural fluid \1as blood-tinged in one patient (Case 5). X o eYide11cc of cluhhingor pulmonary c,steoartliropathy was present in any of our patients. Metastatic nndu le,; were found on the chf'st wall in Case .f. apparPntly at the site nf one ()f snr:d thnr:1rnccntese~. and on the scalp in Case S The metastatic nodule on the chest wall illustrates ho,,- this tnrnour can spread along tlw track made h_,- needk p11nct11re. The scalp 11tHlt1l<'s i11 Ca~e S were metastatic clcposih. Distant meta~tasis in mesothelioma is unustml, as normally it spreads locally and involves the s11rrn11nding structures hv direct extension (TJr~clwl :rnd Paulson. 1~65). . . Jl.\S ET _\Lll Diagnostic Methods Besides a detailed clinical history, physical examination, and ro11tine imestigatinn incln ding skiagrams of the chest. diagnosri~ modalities such as thoracounte,;is, pleura biopsy, and ultimately exploratory thnracototllY are ;n-ailable to e~tablish the fi11al diag-nos1' Skiagram,; of the chest. if pleural c-ffu~ion i; 11ot present. would rneal tlw intratlinracic o: mediastinal mass ii prrse11t a11d \\ <tild ,how the radiulogical ~ign ()j :--c;1llpi11!..'. LTr,ciit! and Pa 11 b1111. JC)(>~ '1. Thor;1 L11n111 e' , LTtilrl he lll'lpiul in 111c1rt ti1a11 <\Ile 11a.,. Tn ;u]ditiun t" t ncnycrin~ pl rm;tl fl 11id t ';. I;1,t crir ,j,,!'ic:i'. hioclwrnical ;rnd cytl)logiul ,111dic'. Ii dt3r, tl1c 1yay for a bctttr ;;Liagram iJJ "l1i(]; y.:ithou' I it the intrathoracic mass or the :-adic.Jogical sign of scallopinR ccnld he rna'k' <1 J,, th" I rffu,;ion. :\'ttclle ].iop'' of tlw pkm:i ;,, ~; hcrl- side procccl1irC' and ii ,f,nw pr<JlCTh c:1;1 1r,,yi1k the diagno,is. Tlw use nf a 111anualh <pcrail'1 hi_gh speed drill is ;111 illlpr"1 ill<'tlt "l'<T .. onlinarv needle hiop" ITnwncr. the .'.i'adr:wtagt o( rnedle lii"ps_~ i~ thai it prt ., id<'' cnil.1 a s111all piece of tissue. whicl1 111:1kes 1!w dcfin!- ti1e diagrn1-;i' <lifficnlt in the-:e Jii,11.Jngically Yariahle tpmour~ (Prschcl and Paul-:n, 1qfisl. Endosrnpy fias 110 role in the t!iag-nostic work-up. and lymph node hiop3y is t:~nalh- n<;t called for. \YheneHr tl]('se diagno<tic moclah- r ties fail lo yicl<l a histr.iogical rJiagnmi< 1 explnrator_1 thr'1racntom1 beronw,; mcc,,an-. Tr: I all fi1e patirnt~ in this report. e:q1lorawr1 I thoracotonn was <lone with a Yiew \() 'liagnn'i' ~ f ancl pcs~ihle surgical treatment. .i Patl10Touica1 F1af11rcs Tn the cases <k;crihecl in thi,; r<T"i"t. the I taunmd ooufr pweraiscaorfdiav!lcuorraigl inoriigninonien (fCouarser,aIt)i,enitn; ? whom it ga1e rise tn a larr-e rnecli;1'1inal mas, \1-hich encrnarhcd into !lie left hernith1,rax and im-olvecl tlw left 11p11er Johe. thrc'e rnticnt; I had recurr(nt and per;.i,;tent plcnr:il effusion ~ (Cases 3, .t and _;I. and repeatrrl hacterio- ~ lngical and cytological studies ''ere 1111rewarrl- ' ing in all fi,r. Gro:;s patl1ological features 1 ~ir\ according to the tvpe nf the tumour. The snlitarv type is often -encapsulated. pedt1ncula1ed. ::11cl ca;:ih \ rcmo1ahle. whereas the diffuse or :nnlign<int me"nthelioma is characterized by finding; I r:l1lgi11g frnlll nlllltiple papillary proj1ctirm; n:i ' \ \IE~< i the \ ., tht' 1:1 rind I ple11r:' pleur:> appt>;1' nf thi den~t: whit. t U !l !<I l t) 1...,. 1i>l>l' ;q1pt::i- \ar!f''..' ]1,Jw In ( <-xte1: :d~r. ma~! .. ,,Ji]i11 ;lll:-?:i \\"t'!"t ' >11 1 ::nd di:q ,] \\"lti cl~ l"1](' '' l'l('!" T1 m:tl iIhI' fli,1 t 111>1; . pati,: 1o.g-i: nf " 1~ill! prr-\ -~ lie j.. "' : YlJ~ :d,r ,., '.lie 11: ;ll :1. ..; 1( JI ~ ; .. fl hr t; :1r:1 1 ! l"llll \ ~_l"]iC' ; all(l i 11f :it :L:1: I 1(1( \ r-.. .\!FSOTHEL!O).I.\ I:\ 1:\lll.\ the visceral and parietal pleural surfaces to the encasement of the entire lung in a thick rind of tumour tissue involving the visceral pleura with similar findings in the parietal pleura ( P r:->chel and Paulson, 1l)()5). The appearance of the tumour, in general, consists ,,f thickened Yisceral or parietal plema with dense fibrous, firm. pink, white or yellowish- \\"hite nodules or plaques. In our Case r, the wmour originated frolll the pericardium, grew 10 become a big mass. and infiltrated the upper Johe of the left lung. It had a variegated :q;peara nee. rn Case 2, the tumour was also 1ariegated in appearance. Though the lower lnbe wa' stuck to it. it was well circumscribed. In Case 3. the tumour \Vas reallv diffuse and cxtensin'.. It had encased the left lung and abn infiltrated it. The parietal pkura was also markedly thickened and nodular and had "liliterakd the cardiophrenic and co~tophrenic ang-Ie~. Tn Cases 4 and _;, the gTnss appearances 11Trc more or frss the sa111e. The le~io11 was ,,11 th(' right side in both. There \\as diffu:-e :!nd nodular gn111th nYer the llledia~tinal. ,Jiapliragmatic and posterior p:lrictal pleura. 1rith nll!ltiple small deposits <'very1Yhere Tn Ct~t ; there 11as a metastati, dq1nsit 011 the LLeot wall. and in Case :; there were nmltiple :;'.c'l:t~ta! i, nodules in il1e scalp. ' Tn this series. thtTC \\TH' ionr diffo,;t 111alig1nnt 111es11ihcli1.mas arnl one benign 111eso thc1i"1n:1. 1h1u;.J1 tlii..: 11a..: nt>! lnralized. Il isl< ilnc;icalh. t IHre 11ere f\11 i cases of 1ulnilt111:q,ill::ry t11w (Cis,s 1 ai:d .\l T11(l p~1tit11b IC1:-;es 2 and .\) fell i11t1 the histo1Pgica1 c:tte~ory of fihrcu:-< n1c..:otlwli(l111a. One nf these t11mours 1 C::ise 2) \\'as benign. Hinll,r)Jliic cir mixc-rl histological features 11ere pr<,l"n1 in Case _:;. Tlnt::i the e<ises in this report l1l'l1111gtd ;(} t!1t t!irl'c principal histolo~ical rq,t~ <11 :1w~otfwlirH11a. Yiz .. tuhulopapillarv. ;i!ir,,11- :t11d hi1111irpl1ic (Oels l'f a!ii. 1q71 ). 111 r;,,. tul1tilr1papillary ;aridy, tlwrc is an altl'l11pt :tr aci11;1r anti papillary fortllation 11itlt occa- ;iunal -ht-els of epithelium-like cells. The fihron~ 11 ~<Jtheli1i111a consists of spindle cells :ind collagL'll11tt,; fibres and rcse111hles fihru:iar,-oma. The liirnorphic variet~ is realh a mixed , 1pc and prcst11ts a 1aried mixture of t'pithelial ~ml filirous elc111enh. The i11tcrcsti11\'.. fcatnn ,1i !lw lii1>lr1gical lich;l\iuttr uf 111e.;otJ1dioma i.; rhat it> benign hi~topatholngical appearance ,J,Jc,; 111: ll('t'l'~-;arily 111ea11 that the t1111H11r i~ I> \S ET ,\f.ll indeed licnign, and similarly its malignant picture dues not necessarily correspond with its !Jcuign liehaviour ( Urschcl and Paulson, 1965). Distam tllctasta~is i' t111co11111Hl!1 in mcsot.helio111a. In our cases, evi<lcnce of metastasis, by direct extension or by h<.ematogcnnus spread tu remote area,;, was found in four patients. 1n Case 3 the tu!llour deposits wen~ ft 1n11d in lung- ti,;~11C'. apparcutl y dul' to direct cxt.cnsiou, and in Case r tl1c pericardia! 1nesothelionn had itll'adrd the lung li1' direct extension. The tumour deposit 011 tl;c chest wall along the ncrdlc track of a thoracocentesis, seen in Case .+, is an interesting finding and brings the hazard of the needle puncture of a tumour into sharp focus. The only example of distant 111etasta~is wa~ cl'Cll in ca~c S Cla!:dt ct alii (lf)52), Ksltirsagar ct a/ii ( 1q;-1 ), and Reddv ct alii ( 1'J73) found 110 t1idcucc of distant metastasis in their cases. Ceneralh., 111etastasis in a case oi 111cs"tlll'lio111a i,; 1;,. direct extension, ln1t OlTa,;ional hmph 1111<fc 111ctastasis kt" been rcpt>rtcd in isolated cast''', partic1tlarlv in the tt1itl1lopapillary \:ariux ( \Vhitcwdl arnl Ra\\clif'fr. 1q; 1). Tl1e finding oi rnctastatic deposits in tlw scalp i11 Case S who had the hin1nrpl1ic type of 111aligt1ali1 11icsntl1cli(l111a. j.; ddi11i1tl.1 :t11 u11u..:ual finrling. T11 three cast's i1; tlii.; npnrt. pul111011ary resectinn ]11.'c:m1< 11C'n',.';;1ry. pru1idi11g an opp"rt1111il_1 to t"\:11ni11t 1111 pul111n11ary ti'""' illr c\idt11ce r1f a.;hc,t11' r11 as]Jl'.;lu~ like bodies, and ;q>11ar111th 11011<' 11,:1; f1n111d. TTrsdll'I :rnd I'aulso11 1 1q(i; 1 al..:11 11nr' 1111al1le j(J ck!llotls! r:.l< :1...:L1.;t11,: 11'1ir1" i11 :1ll\' 11i tlwir case.;. "/'11'11/lllt'I// (/11(/ f 'J"il!/llrJ.\lS Trc;1111 w11t oi 'Ii ff11,r 11 ""''ll lirliorna 111 griwral is n1 ii ,af i,iact ,,.\. ln1l 11 r ! he locilizerl 1ariet_1. _.;1ir~.i1-;tl t"'' 'Jt11 j, 1lw pr<'ferrl',J tlwrapt1!lir 1Jt()(l:tlih. l l"1111Tr. tlw tr('at11ll"111 t1f a rasC' of 111ak~11:u1I 111tsotlwlio111a i.; frw;trati11g. There iia1l' lwl'11 1111 curl's. Isolated i11sta1Kc.; (Jf suni1 al "i i."11r tri '-'ix vcars han' ken riv1rtcd (Lcl~1111x. 1q().2: Fischel ;mrl Paubo11, 1/i;: Porter and Check, I<jl-;8). Ho11'<1 er. malignant 111esoi heli11111as have been treater! 11_1 t11flracntr11m a11rl 1.inpsv. fnllu11ed hr rarliolhn:q>~' and dw111r1thC'rapv. Earlier. plettrup11e1~111011tTto111y 1yas advocated. even if it \\"a..: sulitoL!. to ;1ccornplish an obliterative rea,t in11 a11d prl1r11t rcfnrmatio11 of pleural 225 'I "I i.::-; (Ji 111 :I !( I\ I \ I ,\ l \ i Ji \ i111id I l 'r:-.clH'I all<! f ';111i ii, 1ql1) J. Tlw t lll' r{'n! trc1Jd i;; j(J treat these patients wit11 cinse.J t u],1 tl1oracisttJlllV. :\,; ;111 .;tltcrnati1< tu :-urgic:d c\cisio11. ra:li<tlicr;1v1 ;1ml 1lic1nfltlwr;1p" l1a1c liccn used. \Vi.Jc: 1 :1ri:1!i"n i11 rc.s1tlts :u:d suni 1-;d time" make, :1111 critical <1:t111a1 io11 .Jiffirnlt. :\ennlwlc,,. 1:i'.liuilier;.!]1\' i' rcc11111rncnded when excisi1 11:l1 :-.1irgtTy i~ i111p. '"silik or i11cu111plete ( f.cf~1n1x. T<102: l'ortcr a11d Check, J t/j8). Ursclil'I :.111J I'aulson ( rqr,s; also noted impro1Tn1ern in rnany of tl1eir p:1tie11ts iollowi11g rarlintlwrapy. Tn this n1iew. the result of surgical extirpation with a good surgical margin has lwc11 q<iik ~'/Mrl in two patients (Cases 1 :iwl !. 1, hut in a third patient I Case ~). in wlw111 c1111 with pleuro- pneumonectomy th(' rc~crliou of the tumour was incomplete, surgical t rl'atrnent had to he suppl<'111e11te<l with radiotherapy and chc1110- thcrapy. rn the rr111ai11i11g t \\'() paticllts the tumour was not rescctahlc "II c'.xplnration. Radiotherapy in conjunct ion \\'ith chemotherapy ( cyclnplwsphamick) proved quite bcncficial in Cases 3 and 4. They exprrienced C()11sidcrahle irnprn\'enw11t in lheir general co11dit io11. with relief of pain. a11d there was r<'<lurticin in the size CJf the 111a~s. Thcse patie11ts are still doing well, ten and eight rnonth:i respectively following tlwir diagnosis. How c1Tr, there was 110 rcspoti:;l to radiotherapy and chemotherapy in our Case S Actuall\', the patient started going do\\'nl1ill anrl had already developed distant metastases. Two patients. Cases r and 2, who !1ad sati~fadory extirpation of their tumours. ;ire doing well and have re111ained asymptornat ic 26 . and 24 rnomhs respectively si ncr their smgrrv, \\ith nu nidenrc of rccurTrncc or clisse111inatio11. Thl'. prng11osis in r11alit>,1iat1t 111esot11clio111:1 is ponr. :\fost patiC'nts die within a yrar nr two fnJ111 tlw time of diagtHJsis. The progwi,is i,; worst i11 patienb ,,ith tlie liimnrphic 1-ariety nf tlic tumour. Tlw vari;11im1 i11 st1!'vi1al ha<; I> h i'T .\/ !! "" Ltr r;111''."il fr11111 frn1r 11111tlis (_1 ti\'l~ ;c:n ; t_:rscL('l and l'auhun, Jt_/J5). H.FFI:RE:\CLS .\1K.1;, U h... K1!J!L\KJUSH:\A:;, V. \ ;u1d ;d.1L!> .\. k_ l Iti/4), liidiuu .I. Cu11ccr, 1_. 95. , HuH1<1w11" \!.. Cox,;:ux, :\. I.1101;.\J:SE, L. :11:-> C:,1:.,1.1.1, .\. (1w31, Dis. Cflest. 6.1: (l_p, , Lw11 s, \\'. I. ;u!l[ lllllNSox. L. C. 1!(J.}r), JI:::: Surg., IU"J: -P5- . . - C:JL\X!JCHKAR, S. ;\., l.,:JL\XJJEK.\I~, " I SHJ\T' :\. V. am! Knrn, A. \-. (1975 ), /,;:!i11,;; J. Ch<." J)is.. 1i': 139- l-L.\GE'I 1, 0. T., :\kl lti:\',\LD, J. I\. and Sc!Dtll . H. \\'. (1052), .I. thora,., S;rr[/., -'-i: 213. G1WNIJY, (;. \\'. and :\hr.r.rn, T\. \\". (1972), (mtr'" (l'hilru/.), :;u- 12rG. t ,t. If1,u(1trA;.;1:, I>. 0. (1sm4), Tlumz.r, 11. J,,~. Ht:r1,R, Vv. C. ( 1964), J. 1\/111. Cm1c,'r !list, 33 100:. c. Ku~MPEllEH, P. :ind R.\l,IX, n. (11,31 ), .lr.-h. ]'11th' II : 3b5. n. Ks11rns_\GAI(, V. If .. l'\TIL, S. n, Sil.II<\!\, K. DESlll'l'.\IJJE, T. V. and ])1~11\!.\).T, J. V. (1971). l hidia11 J. Can, er, P.: :?OP.. l.1-:Roux, fl. T. (11)62), Thorax, 17: 111. t \[ANGUIKTAN, B. and P1<rn1<, .f. T. (1()63), Arri:. l'ath., 75: 236. t c.. Oas, 11. I LIRl(ISIJ", E. ( ~' ( """' n. T. am! ' JfrRNA1z, P. E. (1971), T"iis. Ch>'sl, 60: 56~. Po1nrn, J. :\f. and Cm:EK, J. \!. ( 1968), J. thora<. cardin:11.1c. Surg .. 55: 8P.2. I\ Ellll)'' n. .1. ( 1())0)' fodi.m .r' Surq.. I 2: 305. REDDY, ll. B.. l '11.\!':G.\L RAJC, (; .. \-EXK.\T::-L\!!.WA:\.\, G. P. and Slv.11C\AKe:-1.11n, G. (H173), J. A.is. !'lzyrns fodi:t 21 : 453. l<OllFlflSON, rr. 1'.. (Hp.j), J. lUlllt'r Rl's.. 8: 317. S.\XO, M. E., \\TEISS. E., and G.\l'LT. E. S. (rnso), J. tlJ1Jrt1c. S11r,11 .. 1r;: /83. SELTKOFF, T. V. Cnt:ra;, ]. and HA.\Droxn, E. \. (H16,J), J .. l111>'r. 111rd. Ass.. 188: 22. Snnn, :\. l'. and \fp1~1~.\Y, \f. R. (1o_p), -lrch. l'ath 3.+: 95r. URc.c:m:r., H. C. anr! P.H'LS1JX, D. L. (1965), Ann. thorar. Sur!/. r: :;::;I). \\'1c:-.:ui, J C. (1q62), Nature (l.n:ui.), 1q6: iSn. \VAC;.'\rn, J. C.. Su:ccs, C. A. :ind ~\l11<C'T 1s1., P. \ (1960), T?rit. J. industr. Jfcd .. 17'. :60. l \\'1u.1s. l~ .. \_ ( 1067), "Patl1nlog" or T11:11"urs", .1; 1 et!itirn1, l'.111tcr11or11is. \\'asliington, fi.C : I~n. I \VHlTE\\'ELL, '' and R \ wcu FFF, R. \f. ( 1971), Tllorn:r, ::>6: 6. TRAU:--1. THAl ' T1n1 child [, ~ll rgt.'E '1' the ac di,Jo~;,1 and 11 \1 Stnw prl'vi I\ T\i, su rvv:1 are~t 1 \ ;;kl'k1:1' 2~ ti) 1 r -:-i .\ , Th oi 1Iw of t.h Ti "'it 1ll" al)11(1r~ 11\0( il or ]111 radi11l. ( )' 226 .\t'ST. X.Z. J. Su;., VoL. 46--- ~o. 3, Avct:sT, I()/ I I Zc:!I"" I~ ( (ht!: J{ct1o I .\r:--