1. Chronic organized empyema
2 .metastatic adenocarcinoma
3. sarcoma
Side A- Describe the clinical course of mesothelioma
Side B- As the disease progresses patients develop chest pain and shortness of breath.
Fatigue, dyspnea and hypoxia ensue. As the lesion invades thoracic structures, the following complications may develop.
- dysphagia
- hoarseness
- cord compression
- brachial plexopathy
- Horner’s syndrome
- superior vena cava syndrome
- disseminated intravascular coagulation
- migratory thrombophlebitis
- thrombocytosis
- coombs-positive hemolytic anemia
- hypoglycemia
- hypercalcemia
Establishing a diagnosis of mesothelioma is difficult. At this point serum tumor markers have no role in the diagnosis or screening of mesothelioma. Having a high degree of suspicion due to history will help.
Chest CT is important to detect invasion of the chest wall, ribs and mediastinal structures.
Video-assisted thorascopic biopsy is the preferred method. Thoracentesis or closed pleural biopsy may help but may not provide enough tissue to differentiate between mesothelioma and adenocarcinoma.
Bronchoscopy and mediastinoscopy will also help in establishing the diagnosis.
Clinical presentation is similar to most pulmonary problems. Nonpleuritic chest pain and dyspnea are the most common. During the evaluation, chest x-ray may show a unilateral pleural abnormality or pleural effusion, diffuse pleural thickening or a pleural mass or ipsilateral mediastinal shift. Loss of lung volume is common.
Physical findings may include dullness to percussion, palpable chest wall masses or scoliosis to the side of the malignancy.
Mesothelioma is a malignant neoplasm that affects the mesothial surface of pleural and peritoneal cavities, most commonly the lung, but has also been found in the pericardium and tunica vaginalis. It has been linked with asbestos exposure in up to 70 % of the cases and generally presents in people 50 to 70 years old. Asbestos is still used for cement, ceiling and pool tiles, brake lining and ship building so taking a good history is important to establishing the diagnosis.
A cancer care team will recommend one or more treatment options for the patient to consider. Surgery for pleural mesothelioma may be done to relieve pain (palliative surgery) or it may be curative surgery which is offered if a patient is in good health and the tumor can be removed completely. A thoracentesis, where fluid in the chest is removed by placing a needle into the chest cavity, may be done to make a patient more comfortable. A procedure called pleurodesis in which talc or drugs that cause scarring may be injected into the cavity to prevent the fluid from returning to the chest cavity is also used. In peritoneal mesothelioma, a needle may be inserted into the abdomen to drain the fluid. Similarly, fluid may be drained from the pericardium by inserting a needle. Surgical treatment of peritoneal mesothelioma is done to help relieve symptoms or to remove the tumor from the wall of the abdomen and other digestive organs. Chemotherapy is another option for treating mesothelioma. Chemotherapy is the use of drugs for treating cancer. When treating mesothelioma, these drugs may be given intrapleurally (directly into the chest cavity), or intraperitoneally, (into the abdominal cavity). Chemotherapy may be given as the primary (main) treatment or as an adjuvant treatment (treatment given in addition to the primary treatment) to surgery. Chemotherapy for this disease is palliative and not curative. Radiation therapy is sometimes used as the main treatment of mesothelioma in some patients who are unable to undergo surgery.
The first step in diagnosing mesothelioma is to check for risk factors and symptoms. This is done during the medical history interview and physical exam. Most people with mesothelioma have symptoms for only 2 to 3 months before they are diagnosed and about one-fourth have symptoms for at least 6 months before they are diagnosed. Most patients with pleural mesothelioma have pain the lower back or at the side of the chest and report shortness of breath. A few of the people have trouble swallowing, cough, and have fever, sweating, fatigue and weight loss. Some of the other symptoms include hoarseness, coughing up blood, swelling of the face and arms, muscle weakness and sensory loss. Abdominal pain, weight loss, nausea, and vomiting are symptoms of peritoneal mesothelioma. A physical exam will provide information about signs of mesothelioma. These signs include pleural effusion (fluid in the chest cavity), ascites (fluid in the abdominal cavity), and pericardial effusion (fluid in the pericardium). All of these signs may be caused by cancer. Imaging studies such as x-rays, computed tomography (CT) scans, and magnetic resonance imaging (MRI) scans will help determine the location, size, and extent of the cancer. Test of fluid and tissue samples are also examined for cancer cells in diagnosing mesothelioma.
The main risk factor for mesothelioma is exposure to asbestos. Asbestos is a natural mineral that can be found in dust and rocks in the United States. Asbestos was used in the past in products such as insulation, floor tiles, and roofing. Most use of asbestos was stopped in 1989. Asbestos fibers that are breathed in can travel to the lining of the lungs causing damage to lung cells. These damaged lungs cells can lead to pleural mesothelioma. When swallowed, asbestos fibers can reach the lining of the abdominal cavity where they can contribute to the development of peritoneal mesothelioma. People at risk for asbestos exposure include some miners, factory workers, and makers of insulation, railroad workers, ship builders, gas mask makers, and construction workers. The risk of getting mesothelioma depends on the amount of asbestos a person was exposed to and for how long. The time between the first exposure and developing the disease is often between 20 and 50 years.
There are an estimated 2,000 to 3,000 new cases of mesothelioma each year in the United States. Mesothelioma is a rare disease. It is rare in people under age 55 and its incidence increases with age. People over 65 years old make up ¾ of people with mesothelioma. Mesothelioma is more common in white Americans than in African Americans. Men are much more likely than women to get the disease. Mesothelioma is often in an advanced stage when it is diagnosed. The average survival time is about 1 to 2 years. The 5-year relative survival rate is around 9%. The 5-year relative survival rates do not include patients dying of other diseases and are considered to be a more accurate way to describe the outcome or prognosis for patients with a particular type or stage of cancer. The 5-year survival rate refers to the percentage of patients who live at least 5 years after their cancer is diagnosed.
Mesothelioma is a type of cancer that begins in the tissue that lines different organs and spaces inside the body. This tissue is called Mesothelium and protects organs by making special fluid that allows the organ to move. This type of tissue surrounds the lungs, stomach, heart and other organs. The mesothelium of the chest is called the pleura and the mesothelium of the abdomen is called the peritoneum. The mesothelium of the space around the heart is known as the pericardium. Cancerous tumors can start in any of these places. These tumors are called malignant mesothelioma or simply mesothelioma. Mesotheliomas are divided into 3 sub-types. These sub-types are based on cell type and are epithelioid, sarcomatoid, and mixed/biphasic. The epithelioid type accounts for about 50 to 70% of malignant mesotheliomas. Sarcomatoid account for 7 to 20% and mixed/biphasic 20 to 35% of the sub-types of mesotheliomas. Pleural mesotheliomas (tumors that start in the chest) comprise about ¾ of all mesotheliomas. Another 10 to 20% begin in the abdomen (peritoneal mesotheliomas). Pericardial mesotheliomas start in the cavity surrounding the heart and are very rare.
Even with treatment, prognosis is poor. Average survival is about 1 ½ years after the onset of symptoms. The 3-year survival rate is 10%; 5-year survival rate is only 5%.
Conventional treatment of mesothelioma includes surgery, radiation, and chemotherapy. Surgery is usually performed palliatively or to remove the tumor in hopes of a cure. Surgery for cure is often futile because there is usually microscopic spread of the cancer cells even when the tumor appears to be isolated.
Radiation may kill the cancer cells and is frequently used adjuvantly with surgery. When performed along with chemotherapy, radiation can cause the side effects of chemotherapy to be worse.
Chemotherapy may be used as a primary or adjuvant form of therapy along with surgery and radiation. A combination of chemotherapeutic agents is often given.
Experimental treatments of mesothelioma include drug therapy, gene therapy, and immunotherapy. These treatment methods are currently being studied.