Pleural Mesothelioma

Clinical History

60 years old man, ex smoker, developing a respiratory failure unresponding to specific treatment.

Imaging Findings

The patient, an ex smoker without history of asbestos exposure, due to dry cough associated with dyspnoea, underwent a chest X-ray, that revealed basal congestion of the right lung and pleural reaction. After an antibiotic therapy cycle of Ceftriaxon, clinical conditions didn’t improve and the subsequent radiogram showed a general worsening of pulmonary state, characterized by increased pleuric effusion. Besides, spyrometric tests demonstrated a respiratory failure of restrictive type. Afterwards, the patient underwent computed tomography of the chest that revealed an advanced state of a malignant pleural affection of the right lung, characterized by volume loss of right hemi-thorax, a circumferential involvement of the hemitorax, chest wall, mediastinum and diaphragm. The study revealed also some osteolytic areas involving sternum body, C7, D2 and D11.

Discussion

Malignant pleural mesothelioma (MPM) is an uncommon neoplasm that arises from the pleura and, rarely, from peritoneum or pericardium. It’s the most frequent primary neoplasm of the pleura. MPM is strongly linked to asbestos exposure: approximately 80% of these lesions occurs in individuals with documented history of asbestos exposure. For these individuals, the average latence period is 35 years. Other etiologic factors are involved: exposure to other mineral fibers, chronic inflammation, heredity, irradiation, viruses and there is also an influence of cigarettes smoking. Histologically MPM may be epithelial, mesenchimal or mixed. Radiologically, it usually shows some pathognomonic signs: nodular pleural thickening, unilateral pleural effusion, interlobar fissure thickening, pleural calcifications and coarctation of the affected hemitorax. MPM is locally aggressive, with frequent invasion of the chest wall, mediastinum and diaphragm. Lymph nodes metastases occur in 50% of cases, including hilar, mediastinal, anterior dyaphragmatic and internal mammary nodes. The most frequent sites of metastases are bone, adrenal glands and kidneys. Several factors have been shown to correlate with reduced survival time: intrathoracic lymph nodes metastases, distant metastatic disease and exstensive pleural involvement. The prognosis is poor: 12 months of median survival time. Computed tomography is the primary imaging modality used for the diagnosis and staging of MPM thanks to its sensitivity in detecting MPM pathognomonic signs.

Differential Diagnosis List

Final Diagnosis

Pleural mesothelioma with lymph nodal and bony metastases.

URL:	https://www.eurorad.org/case/4734
DOI:	10.1594/EURORAD/CASE.4734
ISSN:	1563-4086