The Imaging Journey of Patients with Malignant Pleural

Mesothelioma: Experience of a Tertiary Mesothelioma MDT

Exhibit Category: Thoracic Neoplasms

V. Lam, J. Brozik, A. J. Sharkey, A. Bajaj, D. T. BarnesGlenfield Hospital, Leicester, United Kingdom

Disclosures

• None

Learning Objectives

• Imaging features of malignant pleural mesothelioma (MPM), from presentation to palliation

• Optimum CT imaging technique• Means of obtaining histological diagnosis • Role of CT in determining radical versus non-radical

surgery• Normal and abnormal post-intervention appearances • Multi-disciplinary based approaches to managing end-

stage MPM

Presentation

• Unexplained unilateral pleural effusion and/or thickening

CT Technique• Pleural protocol

– Entire pleural and diaphragmatic surfaces required from apices to pubic symphysis

– 60 second delay– 150 mls at 2.5

mls/second– 1.5 collimation

Common features of MPMMediastinal irregular pleural

thickeningCircumferential irregular pleural

thickeningInterlobar fissural

involvement

Uncommon features of MPMDiscrete pleural noduleMediastinal invasionExtension beyond the diaphragmChest wall invasion and bony destructionMetastases at presentation

Role of MRI in MPM

• Not routinely used to evaluate MPM

• Mainly used as a problem solving tool for detecting invasion of vessels, cardiac structures, endothoracic fascia, and diaphragm

• Modality of choice for those in whom iodinated contrast is contraindicated

PET-CT

• Adjunct in diagnosis and staging

• F-18 FDG uptake is higher in MPM than benign conditions 1

• Potential use of PET-CT guided biopsies

• PET-CT can give false positives with infection, inflammation, or after talc pleurodesis

PET-CT Images

Benign or malignant pleural disease

• Yilmaz et al.2 :– Favour a malignant process when:

• Nodular pleural thickening• Mediastinal pleural thickening• Parietal pleural thickening > 1 cm• Circumferential pleural thickening

– Specificity: 97 %, 85 %, 85 %, 97 %– Sensitivity: 37 %, 31 %, 35 %, 22 %

Mesothelioma Mimics Talc in chest wall leading to a giant cell

reaction

↑↑ ↑ ↑

↑Mucinous cystic tumourLung cancer with pleural effusion

Diagnosis

• Thoracoscopy 3, 4

– Investigation of choice– Also allows placement of drains or pleurodesis– Diagnostic sensitivity of 94 % for malignancy

• Percutaneous biopsy

• The increased sensitivity of thoracoscopy has led to a decreased use of aspiration and percutaneous pleural biopsy

Staging

• The 8th edition of the TNM classification for malignant pleural mesothelioma is due to be released by IASLC

• Important for stratification of patients– Treatment options– Clinical Trials

• However, there is relatively poor correlation between CT and final surgical staging

Volumetric assessment

• Volumetry may be useful for pre-operative assessment 5, 6

• Currently, quite labour intensive

• Computer assisted methods are being investigated

Treatment options

• All treatment should be thought of as palliative– Active supportive care– Drain– Chemotherapy– Cordotomy– Surgery

Lung Sparing Pleurectomy Decortication akaRadical P/D aka Extended

Pleurectomy/Decortication

• P/D that removes ALL macroscopic disease

• Full parietal pleurectomy• Visceral decortication

extending into fissures• Removal of pericardium

and diaphragm and reconstruction with synthetic patches

Pleuropneumonectomy, aka Extra Pleural Pneumonectomy (EPP)

• En bloc removal of pleura, lung pericardium and diaphragm.

• Reconstruction of pericardium and diaphragm with synthetic patches

Contraindications to radical surgeryMediastinal invasionInvasion of pericardial space and mediastinumPeritoneal diseaseInvolvement of subclavian vesselsVertebral body destructionNeuroforaminal involvement

Follow up – normal patch appearances

Complications post surgery

*

Chylous collection

Patch dehiscence

Pneumothorax and subcutaneous emphysemaDiaphragmatic patch rupture post EPD

Talc pleurodesis in chest wall leading to granuloma formation

Percutaneous pleural biopsy

Recurrence - Needle tract seeding

n = Incidence of Needle Tract Seedlings 4

Aspiration 55 2 (4%)

CT Core-Needle Bx 22 1 (4%)

Chest Drain 55 5 (9%)

Thoracoscopy 51 8 (16%)

Thoracotomy 21 5 (24%)

Recurrence - Needle tract seeding

Progression – role of serial CT

Palliative measures - Pleural Drains

• Removal of fluid may relieve pain and difficulty in breathing

Therapeutic drain for malignant mesothelioma spread into the peritoneum

Take Home Messages

• Radiology is key to management• Pleural phase CT is vital• CT helps discriminate between radical or non-

radical surgery

References1. Sharif S, Zahid I, Routledge T, Scarci M. Does positron emission tomography offer prognostic

information in malignant pleural mesothelioma? Interact Cardiovasc Thorac Surg. 2011; 12(5): 806-11.

2. Yilmaz U, Polat G, Sahin N, Soy O, Gulay U. CT in differential diagnosis of benign and malignant pleural disease. Monaldi Arch Chest. Dis. 2005; 63 (1): 17-22.

3. American Thoracic Society. Management of Malignant Pleural Effusions. American Journal of Respiratory and Critical Care Medicine. 2000; 162: 1987-2001.

4. Agarwal PP, Seely JM, Matzinger FR, MacRae RM, Peterson RA, Maziak DE, Dennie CJ. Pleural mesothelioma: sensitivity and incidence of needle track seeding after image-guided biopsy versus surgical biopsy. Radiology. 2006 Nov; 241 (2): 589-94.

5. Liu F, Zhao, Krug LM, Ishill NM, Lim RC, Guo P, Gorski M, Flores R, Moskowitz CS, Rusch VW, Schwartz LH. Assessment of Therapy Responses and Prediction of Survival in Malignant Pleural Mesothelioma through Computer-Aided Volumetric Measurement on Computed Tomography Scans. Journal of Thoracic Oncology. 2010; 5 (6): 879-884.

6. Chen M, Helm E, Joshi N, Gleeson F, Brady M. Computer-aided volumetric assessment of malignant pleural mesothelioma on CT using a random walk-based method. International Journal of Computer Assisted Radiology and Surgery, 2016; 1-10. doi:10.1007/s11548-016-1511-3

Presenting Author Contact Details

• Dr Daniel T Barnes• Consultant Radiologist• University Hospitals of Leicester, Glenfield

Hospital, Leicester, UK, LE3 9QP

• Email: Daniel.T.Barnes@uhl-tr.nhs.uk• Phone: 0300 303 1573