Chest MRI

Description

Το μεσοθηλίωμα αποτελεί κακοήθη νεοπλασία των μεσοθηλιακών κυττάρων της υπεζωκοτικής και της περιτοναϊκής κοιλότητας.

Histology

Το μεσοθηλίωμα εμφανίζεται με τους εξής ιστολογικούς τύπους:

• Mesothelioma in situ (άτυπος πολλαπλασιασμός μεσοθηλιακών κυττάρων)
• Κακόηθες μεσοθηλίωμα
  
  • Sarcomatous type
  • Epithelioid type
  • Mixed or two-phase type

Epidemiology

The occurrence of mesothelioma is usually found in populations:

• Adults 40-80 years old
• 70 - 80 % in men

It is related to occupational exposure of people to asbestos:

• 80% in men
• 40% in women

Possible risk factors

• Occupational and environmental exposure to asbestos
  
  • Aeronautics
    • Aircraft Engineers
    • Aircraft builders
  • Electricity industry
    • Electricians
    • Installers of electronic and telephone lines
    • Workers in power plants
  • Shipping
    • Shipbuilders
    • Sailors
    • Coastguards
  • Brake and clutch industry
  • Building industry
  • Workers in refineries, railways, refractory industry, rubber industry, waste management, demolition, building maintenance, 
  • Mining and production of asbestos and gold
• Exposure to other fibres (erionite, fluoro-edenite)
• Genetic predisposition to mesothelioma (may be associated with autosomal dominant transfer to offspring)
• Exposure to ionising radiation (e.g. radiotherapy)

Etiology and Pathogenesis

• Causes
  
  • Asbestos
  • Fibres erionite, fluoro-edenite
  • Refractory ceramics
  • Ionising radiation

• Pathogenesis

 The average latent period of asbestos exposure until the onset of mesothelioma is 40 years (15-67). It usually develops in the mural pleura. The mechanism of development is probably related to the irritation caused by inhaled asbestos fibres and the impending destruction, inflammation and repair process in the wall pleura. In addition to mechanical irritation, asbestos fibres can cause damage to the mitotic spindle during cell proliferation, as well as damage to the structure of chromosomes. Finally, asbestos induces the production of iron-related reactive oxygen species that can cause damage to the genetic material of cells, as well as activation of kinases that increase expression in the early response to proto-oncogenes.

Symptomatology

• More likely:
  
  • Chest pain
  • Shortness of breath
• Less likely:
  
  • Palpable masses on the chest wall
  • Weight loss
  • Weakness
  • Sweating
• Rarely:
  
  • Hemoptysis
  • Voice gill
  • Dysphagia
  • Lymphadenopathy

Clinical examination and signs

• Circulatory
  
  • Pericardial collection
• Respiratory
  
  • Lateral collection
  • Atelectasis
  • Chest wall masses
• Ends
  
  • Upper limb cramps
• Nervous
  
  • Horner syndrome
  • Spinal cord compression

Diagnostic approach

• Biochemical tests
  
  • Soluble mesothelin related peptides
  • Osteopontin)
  • Megakaryocyte potentiating factor – MPF
  • Fibulin-3
• Imaging tests
  
  • Chest CT
  • Chest MRI
  • Whole-body PET-CT
• Biopsy
  
  • Thoracoscopic pleural wall biopsy

Staging

Stage                T            N            M

Stage I             T1         N0         M0

Stage IA         T1a         N0          M0

Stage IB         T1b         N0          M0

Stage II          T2           N0          M0

Stage III       T1-T2     N1-N2       M0

                       T3       N0-N2      M0

Stage IV           T4       Any N       M0

                    Any T       N3         M0

                    Any T     Any N       M1

Address

• Treatment of patients with stage I-II and mixed or epithelioid histology includes chemotherapy and/or surgery
• Surgical treatment is divided into:
  
  • pleurectomy of the pleural wall and visceral pleura (pleurectomy-decortication)
  • extrapulmonary pneumonectomy
  • cytoreductive or debulking surgery
  • intrathoracic, regional, hyperthermic chemotherapy
• Radiotherapy is used as an adjuvant
• Immunotherapy
• Multifactorial therapy that combines all of the above

Forecast

• The average survival for mesothelioma is 8-14 months
• Most patients over two years have epitheliogenic type
• Negative predictors
  
  • non-epithelial histological type
  • poor general condition
  • chest pain
  • age > 75 years
  • men
  • platelets > 400000/mcL
  • LDH > 500 units/L
  • high uptake on PET-CT