DIAGNÓSTICO CLÍNICO Y

ESTADIAJE DEL

MESOTELIOMA-ASBESTO

DR. JORDI ROIGNeumología

Clinical Features of Malignant Mesothelioma

Age 40-70 y

Male-to-female ratio 5:1

Risk factorsAsbestos exposure, eg, shipyard workers, miners

Spouse of asbestos worker

Irradiation

Beryllium exposure

Latency period after asbestos exposure

30-45 years

Type of asbestos fiberCrocidolite amosite > tremolite > chrysotile

Incidence Nonasbestos exposure—1:1,000,000

Asbestos exposure—0.2-2:100

History of asbestos exposure 13%-76%

Smoking history 36%-71%

Symptoms to diagnosis

<6 mo 70%

>6 mo 28%

Survival without treatment (after diagnosis)

6.8-15 mo

Reference Sex Exposure Age at exposureAge at

diagnosis

Dahlgren, 1967 F Thorotrast 23 36

Brody et al, 1977 MHodgkin's disease

29 34

Brenner et al, 1982 MHodgkin's disease

27 34

Antman et al, 1984 M Wilms' tumor 3 44

Antman et al, 1984 M Wilms' tumor 6 22

Antman et al, 1984 F Breast cancer 30 40

Antman et al, 1983 FRT to neck scar

29 55

Tester et al, 1984 MHodgkin's disease

23 28

Reference Sex Exposure Age at exposureAge at

diagnosis

Anderson et al, 1985 M Wilms' tumor 2 16

Austin et al, 1986 F Wilms' tumor 4 24

Kawashima et al, 1990

F Breast cancer 34 64

Lerman et al, 1991 FHodgkin's disease

4 24

Hoffman et al, 1994 FHodgkin's disease

13 22

Shannon et al, 1995 F Breast cancer 65 75

Shannon et al, 1995 F Breast cancer 39 74

Weissman et al, 1996 MHodgkin's disease

32 46

Weissman et al, 1996 MHodgkin's disease

7 33

Cugell, D. W. et al. Chest 2004;125:1103-1117

The latent period: pleural changes in 624 asbestos-exposed industrial employees

PATOLOGÍA RESPIRATORIA

RELACIONADA CON ASBESTO

ASBESTOSIS PULMONAR

(FIBROSIS)PATOLOGÍA PLEURAL

ASBESTO Y CÁNCER

DE PULMÓN

PLACAS PLEURALES

DERRAME BENIGNOMESOTELIOMA

PLACAS PLEURALES MESOTELIOMA

PATOLOGÍA PLEURAL

PATOLOGÍA RESPIRATORIA

RELACIONADA CON ASBESTO

Clinical Presentation of Malignant Pleural Mesothelioma (MPM)

Symptoms Observed in Most Patients

Chest pain

Shortness of breath

Weight loss

Other Symptoms

Cough

Hoarseness

Fever

Sweats

Clinical Presentation of MPM

Physical Examination

Asymmetric chest excursion

Unilaterally decreased breath sounds

Laboratory Findings

Laboratory studies are generally not useful in disease diagnosis. However, leukocytosis, anemia, thrombocytosis, and elevated LDH are commonly observed.

Cancer: Principles and Practices of Oncology, 6th ed. Philadelphia,

PA: Lippincott Williams & Wilkins; 2001:1943-1969.

PLACAS ASBESTÓSICAS + DERRAME: ¡¡ESTUDIAR!!

Adams, R. F. et al. Chest 2001;120:1798-1802

Contrast-enhanced chest CT showing a large pleural nodule

Differential Diagnosis of MPM

Often misdiagnosed

Adenocarcinoma may mimic epithelial presentation

Adenocarcinomas from primary lung, breast, stomach, kidney, ovary, and prostate cancers metastasizing to the lung pleura can resemble mesothelioma

Examination of pleural fluid or BCN-FNA aspirates may aid differential diagnosis

MESOTELIOMAS Y SEUDOMESOTELIOMAS

MESOTELIOMA vs SEUDOMESOTELIOMA

PLACAS ASBESTÓSICAS “SOSPECHOSAS”: ¿MESOTELIOMA?

En caso de duda: PLANTEAR TORACOSCOPIA

MESOTELIOMA EN MUJER SIN RELACIÓN CONOCIDA CON ASBESTO

DISTINTOS ASPECTOS ENDOSCÓPICOS

DEL MESOTELIOMA PLEURAL MALIGNO

PLACAS ASBESTÓSICAS +

MESOTELIOMA

(EXPOSICIÓN A AMIANTO>30

AÑOS)

NÓDULOS DIFUSOS

(EXPOSICIÓN A AMIANTO: 18

AÑOS)

Soluble mesothelin-related protein – A blood test (MM)

Sensitivity 83% (n=48) and specificity 100% when compared to other effusions

With lung tumors: ↓ specificity to 95%

Other asbestos exposed: ↓ specificity to 82%

May be increased prior to presentation

Seven of 40 healthy asbestos exposed had ↑ levels and 3 developed MM at 1-5 years

None of other 33 exposed developed MM<8 years

Robinson B et al. Lung Cancer 2005

Brigham/Dana Farber Cancer Institute staging of malignant pleural mesothelioma

The Revised* Brigham/DFCI Staging System for Malignant Pleural Mesothelioma

Stage Description

I

Disease completely resected within the capsule of the parietal pleura without adenopathy; ipsilateral pleura, lung, pericardium, diaphragm, or chest wall disease limited to previous biopsy sites

IIAll of stage I with positive resection margins and/or intrapleural adenopathy

III

Local extension of disease into the chest wall or mediastinum, into the heart or through the diaphragm, into the peritoneum, or with extrapleural lymph node involvement

IV Distant metastatic disease

*Patients with Butchart stage II or III disease are combined into stage III. Stage I represents patients with resectable disease and negative nodes. Stage II indicates resectable disease but positive nodes.

Cugell, D. W. et al. Chest 2004;125:1103-1117

Mesothelioma

Stage Description

T1A Tumor limited to the ipsilateral parietal pleura, including mediastinal and diaphragmatic pleura. No involvement of the visceral pleura

T1B Tumor involving the ipsilateral parietal pleura, including mediastinal and diaphragmatic pleura. Scattered foci of tumor also involving the visceral pleura

T2 Tumor involving each of the ipsilateral pleural surfaces (parietal, mediastinal, diaphragmatic, and visceral pleura) with at least one of the following features: Involvement of the diaphragmatic muscle Confluent visceral pleural tumor (including the fissures) or extension of

tumor from visceral pleura into the underlying pulmonary parenchyma

New International Mesothelioma Interest Group (IMIG) Staging System

Chest 1995;108:1122-1128.

Stage Description

T3 Tumor involving each of the ipsilateral pleural surfaces (parietal, mediastinal, diaphragmatic, and visceral pleura) with at least one of the following features: Involvement of the endothoracic fascia Extension into the mediastinal fat Solitary, completely resectable focus of tumor

extending into the soft tissues of the chest wall Nontransmural involvement of the pericardium

New International Mesothelioma Interest Group (IMIG) Staging System

(cont’d)

Chest 1995;108:1122-1128.

Stage Description

T4

Locally advanced technically unresectable tumor Tumor involving all of the ipsilateral pleural surfaces (parietal,

mediastinal, diaphragmatic, and visceral pleura) with at least one of the following features: Diffuse extension or multifocal masses of tumor to the

peritoneum Direct transdiaphragmatic extension of tumor to the

peritoneum Direct extension of tumor to the contralateral pleura Direct extension of tumor to one or more mediastinal

organs Direct extension of tumor into the spine Tumor extending through to the internal surface of the

pericardium with or without a pericardial effusion; or tumor involving the myocardium

New International Mesothelioma Interest Group (IMIG) Staging System (cont’d)

Chest 1995;108:1122-1128.

Stage Description

N: Lymph Nodes Regional lymph nodes cannot be assessed

No regional lymph node metastases

Metastases in the ipsilateral bronchopulmonary or hilar lymph nodes

Metastases in the subcarinal or the ipsilateral mediastinal lymph

nodes, including the ipsilateral internal mammary nodes

Metastases in the contralateral mediastinal, contralateral internal

mammary, ipsilateral, or contralateral supraclavicular lymph nodes

Presence of distant metastases cannot be assessed

No distant metastases

Distant metastases present

NX

N0

N1N2

N3

M: Metastases

MX

M0

M1

New International Mesothelioma Interest Group (IMIG) Staging System (cont’d)

Chest 1995;108:1122-1128.

Stage Description

Ia T1aN0M0

T1bN0M0

II T2N0M0

III Any T3M0Any N1M0Any N2M0

IV Any T4Any N3Any M1

Ib

New International Mesothelioma Interest Group (IMIG) Staging

System

Accuracy of malignant pleural mesothelioma

Investigations IncludingConfirmatory tests

Demographics Gender and age

Clinical history

Performance status, presence/absence of chest pain, dyspnea, change in body weight or BMI*

As appropriate

Physical examination

“Presence or absence of shrinking hemithorax”

As appropriate

Radiological investigations

Chest X-ray: PA/lateral in-/expiration, pre-/post drainage of pleural fluid

Blood testsHemoglobin, leucocytes, platelets, basic biochemistry

van Meerbeeck JP. Lung Cancer May 2005

Step I, to be considered in all patients at presentation or diagnosis

Investigations IncludingConfirmatory

tests

CT scan of chest and upper abdomen

Spiral technique, with iv contrast, including lowest costophrenic angles, after drainage of pleural fluid

Pulmonary function tests

Forced vital capacity (FVC), forced expiratory volume 1 sec (FEV1)

Bone scanNot routine, to be considered on clinical suspicion only

Standard X-ray or CT/MRI to confirm dubious findings

Brain CT/MRINot routine, to be considered on clinical suspicion only

Step II, to be considered in patients being candidate for any kind of active treatment

Índice modificado de Goldman de riesgo operatorio en cirugía no cardiaca

Edad >70 años 5

Infarto agudo de miocardio en los 6 meses anteriores 10

Galope S3, Ingurgitación yugular, Fracción de eyección <40%

11

Estenosis aórtica importante 3

Ritmo no sinusal o extrasistolia auricular 7

>5 complejos ventriculares prematuros por minuto 7

P02<60 mm Hg ; PCO2>50 mm Hg ; HCO3<20 3

Mala situación clínica general: creatinina > 3, hepatopatía,encamado.

3

Grado I (0-5 puntos): riesgo bajo; Grado II (6-12 puntos): riesgo

intermedio; Grado III (13-25 puntos) y grado IV (>26 puntos): riesgo alto

Area Investigation Patient groupConfirmatory

tests

Diaphragm Chest X-ray, in-/expirationEvery patient considered for radical treatment

Fluoroscopy

Extrathoracic excluding “occult” M1

Full ring FDG-PET scanEvery patient considered for radical treatment

Biopsy of suspected extrathoracic lesions

LaparoscopyInstitutional practice

Mediastinum, excluding T4, N2/3

Cervical mediastinoscopy, VATS, contralateral VATS

Institutional practice

Chest MRI Gadolinium enhanced

EUS-FNA / PET -CT Investigational

Step III: to be considered only in patients being candidate for radical treatment

The consensus panel further agrees on that:

1. The interval within which the assessment has to be finalized should be as short as possible.

2. Recent (<1-month-old) imaging studies should be available prior to invasive procedures.

3. Further research is done with regard to the comparative efficacy of the different intrathoracic techniques (mediastinoscopy, VATS, EUS-FNA) and the value of the newer ones (PET-CT, EUS-FNA).

Monnet, I. et al. Chest 2002;121:1921-1927

Chest radiograph with the implantable port related to the pleural catheter