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Risk factors
Important risk factors for female breast cancer include an early age at the onset of menarche, a late age at onset of menopause, a first full-term pregnancy after the age of 30 years, a history of premenopausal breast cancer for a mother and a sister, and a personal history of breast cancer or benign proliferative breast disease. Obesity, nulliparity, and urban residence have also been associated with an increased risk of breast cancer.
August 26th, 2005
Endocervical polyps
Endocervical polyps are the most common benign neoplasms of the cervix. Please note that the word neoplasm refers to a cancerous growth. They are focal hyperplastic (abnormal cell growth) protrusions of the endocervical folds, including the epithelium and substantia propria. They are most common in the fourth to sixth decades of life and usually are asymptomatic but may cause profuse leukorrhea or postcoital spotting. (blood after orgasm)
Grossly, they appear as typical polypoid structures protruding from the cervical os. At times, endometrial polyps protrude through the cervical os. They cannot be distinguished from endocervical polyps by gross appearance. Microscopically, a variety of histologic patterns are observed, including
(1) typical endocervical mucosal
(2) inflammatory (granulation tissue)
(3) fibrous
(4) vascular
(5) pseudodecidual
(6) mixed endocervical and endometrial
(7) pseudosarcomatous.
Treatment is removal, which can usually be accomplished by twisting the polyp with a dressing forceps if the pedicle is slender. Smaller polyps may be removed with punch biopsy forceps. Polyps with a thick stalk may require surgical removal.
Microglandular hyperplasia
Microglandular hyperplasia refers to a clinically polypoid growth measuring 1-2 cm. It occurs most often in women who are on oral contraceptive therapy or Depo-Provera and in pregnant or postpartum women. It reflects the influence of progesterone.
Microscopically, it consists of tightly packed glandular or tubular units, which vary in size, lined by a flattened-to-cuboidal epithelium with eosinophilic granular cytoplasm containing small quantities of mucin. Nuclei are uniform, and mitotic figures are rare. Squamous metaplasia and reserve cell hyperplasia are common. An atypical form of hyperplasia can be mistaken for clear cell carcinoma. Unlike clear cell carcinoma, it lacks stromal invasion, has scant mitotic activity, and lacks intracellular glycogen
Squamous papilloma
Squamous papilloma is a benign solid tumor typically located on the ectocervix. It arises most commonly as a result of inflammation or trauma.
Grossly, the tumors are usually small, measuring 2-5 mm in diameter. Microscopically, the surface epithelium may show acanthosis, parakeratosis, and hyperkeratosis. The stroma has increased vascularity and a chronic inflammatory infiltrate. Treatment is removal. The squamous papilloma resembles a typical condyloma acuminatum but lacks the koilocytes microscopically.
Smooth muscle tumors (leiomyomas)
These benign neoplasms may originate in the cervix and account for approximately 8% of all uterine smooth muscle tumors. They are similar to tumors in the fundus. When located in the cervix, they usually are small, ie, 5-10 mm in diameter.
Symptoms depend on size and location. Microscopically, leiomyomas resemble the typical smooth muscle tumor found in the uterine corpus. Treatment is required only for those patients who are symptomatic. The cervical leiomyoma is usually part of the spectrum of uterine smooth muscle tumors.
Mesonephric duct remnants
When present, mesonephric duct remnants are typically located at the 3-o’clock and the 9-o’clock positions, deep within the cervical stroma. They usually are incidental findings and are present in approximately 15-20% of serially sectioned cervices. As the name implies, mesonephric duct remnants are vestiges of the mesonephric or Wolffian duct. Usually, they are only a few millimeters in diameter and seldom are grossly visible.
Microscopically, they consist of a proliferation of small round tubules lined by epithelium that is cuboidal to low columnar. The tubules tend to cluster around a central duct. The cells lining the tubules contain no glycogen or mucin, but the center of the tubule may contain a pink material that contains glycogen or mucin.
Endometriosis
When present in the cervix, endometriosis is usually an incidental finding. Grossly, it may appear as a bluish-red or bluish-black lesion, typically 1-3 mm in diameter. Microscopically, the implants are typical endometriosis, consisting of endometrial glands, endometrial stroma, and hemosiderin-laden macrophages. The implants usually gain access to the cervix during childbirth or previous surgery.
Papillary adenofibroma
This neoplasm is uncommon. Grossly, it appears as a polypoid structure. Microscopically, the neoplasm contains branching clefts and papillary excrescences lined by mucinous epithelium with foci of squamous metaplasia. A compact, cellular, fibrous tissue composed of spindle-shaped and stellate fibroblasts supports the epithelium. The stroma is devoid of smooth muscle, and mitoses are rare. Similar growths occur in the endometrium and the fallopian tubes.
Heterologous tissue
Heterologous tissue includes cartilage, glia, and skin with appendages. This type of tumor rarely occurs in the cervix. While they may arise de novo, these tumors probably represent implants of fetal tissue from a previous aborted pregnancy.
Hemangiomas
Hemangiomas in the cervix are rare in occurence and are similar to those found elsewhere in the body.
August 25th, 2005
Congenital Anomalies:
Congenital anomalies of the cervix reflect only the lower part of the spectrum of congenital anomalies involving the müllerian system. The cervix has 3 types of anomalies: fusion abnormalities, congenital absence, and changes due to in utero exposure to diethylstilbestrol (DES) and other nonsteroidal estrogens.
Fusion anomalies
A failure to fuse or incomplete fusion of the müllerian ducts results in duplication of the vagina, cervix, or uterus. Failure of fusion of the distal müllerian duct can result in any of the anomalies discussed below.
Uterus didelphys results from a complete lack of fusion of the müllerian ducts. Duplication of the vagina, cervix, and/or uterus occurs. A longitudinal vaginal septum is present, with 2 separate cervices and 2 separate endometrial cavities.
With septate cervix, the appearance is that of 1 cervix with 2 separate cervical openings. The septum may be partial. The gross appearance is of 2 separate cervices but 1 endometrial cavity. On the other hand, the septum may extend through the entire length of the uterus, with 2 separate endometrial cavities. Depending on the shape of the uterine fundus, the anomaly is either a septate uterus or an arcuate uterus. Laparoscopy is necessary to distinguish between these 2 anatomic variations.
Congenital absence of the cervix
Congenital absence of the cervix usually occurs as part of the syndrome of müllerian agenesis, also known as Mayer-Rokitansky-Küster-Hauser syndrome. This syndrome occurs in approximately 1 per 4000 female births.
Women with müllerian agenesis typically have a blind vagina and normal ovaries. Approximately one third of patients have urinary tract anomalies, and 12% have skeletal anomalies, usually involving the spine. Imaging of these structures should be part of the evaluation.
In women with partial müllerian agenesis, a uterine bud or fundus may be present without a cervix and proximal vagina. If endometrium is present in this uterine bud, hematometra occurs at puberty, producing cyclic abdominal pain. These patients require excision of the uterine bud. Although vaginal patency has been surgically created in a few patients, pregnancy has not occurred in the absence of a cervix.
In utero exposure to diethylstilbestrol and other nonsteroidal estrogens
Changes associated with in utero exposure to DES and other nonsteroidal estrogens are encountered. The epidemiologic association of in utero exposure to DES with clear cell vaginal adenocarcinoma has been known since 1970. The use of DES, which initially was prescribed for thousands of women to prevent miscarriage, was discontinued at approximately that time. However, unique anomalies of the müllerian system are present in women exposed to DES.
The classic anomaly is a hypoplastic T-shaped uterus, referring to the T shape of the endometrial cavity. Defects limited to the cervix, in addition to hypoplastic cervix, include local interesting gross and colposcopic findings.
In addition to vaginal adenosis, other findings unique to in utero DES exposure include the so-called cockscomb cervix, cervical rings, cervical collars, and cervical hoods. The cockscomb cervix refers to the abnormal stromal development causing the epithelium to be thrown into firm transverse ridges in the anterior vaginal fornix, including the upper ectocervix.
Incompetent cervix with pregnancy wastage is a potential problem in females exposed to DES.
August 25th, 2005
Pathologic diagnosis of a breast lesion can be achieved using a number of biopsy techniques. With a larger biopsy sample, greater accuracy and more information are obtained, but this is at the expense of increased invasiveness. Ideally, needle biopsies should be performed after imaging to help prevent distortions of imaging due to hematoma.
Fine-needle aspiration
The least invasive method of biopsy is FNA. The technique of FNA is determined largely by individual preference, which may, in part, reflect hand size and strength. A 21-gauge (green) needle is used most commonly, although a 23-gauge (blue) needle can yield as much information in some people’s hands, with less discomfort and bruising. Some clinicians opt for a hand-held 10-mL syringe, while others prefer a 20-mL syringe used with a syringe holder. Syringe holders allow a vacuum to be maintained easily but can make control of the needle tip less precise.
Disinfect the skin with an alcohol wipe, and pass the needle through the lesion a number of times, while maintaining suction and steadying the breast tissue with the other hand. With all needle biopsies of the breast, appreciating the risk of causing a pneumothorax is important; wherever possible, angle the needle tangentially to the chest wall. Continue sampling until aspirate is observed at the bottom of the plastic portion of the needle.
Transfer the aspirate to the slides. Spread the aspirate thin enough to visualize individual cells. The slides may be air-dried or fixed according to the preference of the local laboratory. Cytospin preparations of the aspirate may allow a greater number of slides to be made.
Wide-bore needle biopsy
A Tru-Cut needle, ideally 14-gauge, is used for core biopsy. Because of the fibrous nature of much breast tissue, adequate samples are best obtained using a spring-loaded firing device, such as the Biopty-Cut system. The procedure is often less painful than FNA despite the wider-bore needle.
Inject local anesthetic beneath the skin. The cores from a few passes of the needle are fixed immediately in formalin. If the lesion contains calcification based on the mammogram findings, x-ray films of the cores are taken to confirm presence of calcification and, therefore, are representative. The risk of bruising is higher than with FNA, and typically a pressure dressing is applied for at least 24 hours.
Often, the samples are large enough to allow detailed histologic assessment, including the type and grade of the tumor and hormone receptor status, but sampling error may occur if the cores are not representative of the entire lesion.
Some centers now provide even wider-bore core biopsies, up to 11-gauge, using the Mammotome vacuum system. This apparatus is relatively expensive, but the technology may lead to new methods of therapeutic excision biopsy without resorting to open surgery.
Excision biopsy
The ultimate diagnostic biopsy is open excision biopsy of a lesion, normally performed under general anesthetic. Open excision biopsy should be reserved for lesions for which some doubt remains regarding diagnosis after less invasive assessment or for benign lesions that the patient wants removed. A wide clearance of the lesion is usually not the goal in diagnostic biopsies, thus avoiding unnecessary distortion of the breast. Ongoing audit is essential to help reduce an excessive benign-to-malignant biopsy ratio.
August 15th, 2005
Mammography
Two-view mammography (ie, craniocaudal and oblique) is the imaging method of choice for breast screening. In the United States, annual screening mammography is recommended with clinical examination in women aged 40 years.
Despite its use as the tool of choice for breast screening, mammography has significant limitations when used in isolation.
Although in general a highly sensitive investigation, sensitivity is much reduced in younger or denser breasts; therefore, mammography is considered inappropriate in patients younger than 35 years. However, many centers are now using mammography in patients aged 30 years and older who are in high-risk groups. Evaluation of breast tissue is not possible when obscured by implants or in the presence of heavy scarring from previous surgery.
The positive predictive value of mammography can be as low as 10%, demonstrating the need for other imaging modalities, such as ultrasound, to distinguish solid from cystic radiodensities.
However, mammography remains the investigation of choice for detecting and classifying microcalcification. Benign microcalcification is characterized by diffuse scattering and crescentic “tea-cupping.” Malignant microcalcification is characterized by isolated clusters, punctate of varying sizes, and a branching or linear pattern.
Mammography is also efficient for helping detect larger patterns of calcification, such as the outlining of calcified arterioles or the coarse patchy calcification of long-standing fibroadenomata.
Other features that raise concern on mammography images include (1) lesions with ill-defined edges, (2) areas of distortion, (3) asymmetry between breasts, and (4) spiculated lesions.
Indeterminate radiodensities can be assessed further mammographically using (1) additional angled views, (2) magnified images, (3) compression images, and (4) alterations in exposure or contrast.
Ultrasound
Mammographic features often require further ultrasound evaluation, for example to distinguish between solid and cystic lesions or to accurately determine the size of a spiculated lesion. Therefore, ultrasound is an indispensable adjunct to mammography and is one of the most useful investigations to perform on a patient with a palpable breast lump.
Ultrasound is becoming ever more sophisticated. Higher resolutions are being achieved, and the introduction of Doppler enables definition of characteristic blood flow patterns. This can aid in separating benign and malignant lesions and distinguishing lymph node metastases from normal or reactive lymph nodes. Tridimensional images may also be useful in the future.
Ultrasonic features of malignancy include the following:
Poorly defined borders
Heterogeneous internal echoes
Disruption of the tissue layers
Irregular shadowing
Superficial echo enhancement
Depth greater than height
High vascular density and flow rates on Doppler images
Features of benign lesions include the following:
Cyst - Absence of internal echoes, marked deep enhancement
Fibroadenoma - Well-defined borders, well-defined internal echoes, and displacement of tissue planes
Lymph node - Well-defined peripheral blood flow on Doppler images
MRI
MRI is a particularly useful modality for detailing architectural abnormalities in the breast and can help detect lesions as small as 2-3 mm. In cancers, it is useful in defining the precise size of the tumor and in detecting multifocal disease. This is particularly helpful when deciding whether borderline cases are appropriate for breast-conserving surgery.
MRI allows for the construction of tridimensional images, and its versatility is enhanced by the use of different sequences, including high-resolution, rapid-imaging, fat-suppression, subtraction, and dynamic sequences.
Dynamic imaging is the most specific sequence and can help distinguish between benign and malignant lesions, which is particularly useful in the scarred breast when looking for tumor recurrence. Dynamic imaging relies on the shape of the time-signal curves using gadolinium-diethylenetriamine pentaacetic acid enhancement; malignancies typically show rapid, strong enhancement because of high vascularity.
Scintimammography
Scintimammography, while less sensitive than MRI for lesions smaller than 1 cm, is more specific for palpable lesions and is useful for detecting axillary involvement.
The label typically used is technetium Tc 99m Sestamibi, a compound that concentrates in mitochondria. The efflux of this label is related to expression of the multidrug resistance protein. Therefore, the size of the signal distinguishes the high metabolic rate of a malignant tumor and may help predict resistance to chemotherapy.
Single-photon emission computed tomography promises to advance scintimammography in the same way that CT scans have advanced plain radiographs.
Positron emission tomography
PET is the most sensitive and specific of all the imaging modalities for breast disease, but it is also one of the most expensive and least widely available. Using a wide range of labeled metabolites (eg, fluorinated glucose [18FDG]), changes in metabolic activity, vascularization, oxygen consumption, and tumor receptor status can be detected. At present, its main use may be for helping detect recurrences in scarred breasts, but it is also useful in multifocal disease and in helping detect axillary involvement.
August 15th, 2005
Clinical history
Many early breast carcinomas may be asymptomatic, particularly if they were discovered as part of a breast screening program. If the patient has not noticed a lump, then symptoms indicating the possible presence of breast cancer may include the following:
Change in breast size or shape
Skin dimpling
Recent nipple inversion or skin change
Single-duct discharge, particularly if bloodstained
Axillary lump
Pain or discomfort is not usually a symptom of breast cancer. The clinician should be alert to symptoms of metastatic spread, such as the following:
Breathing difficulties
Bone pain
Symptoms of hypercalcemia
Abdominal distension
Jaundice
Localizing neurologic signs
Altered cognitive function
The clinical evaluation should include an assessment of specific risk factors for breast cancer, as follows:
Age
Breast cancer is rare in women younger than 25 years.
Incidence increases with age, with a plateau in women aged 50-55 years.
Age is the most significant risk factor.
Genetics
Family history is a risk factor. The lifetime risk is up to 4 times higher if a mother and sister are affected.
Individuals of Ashkenazi Jewish descent have a 2-times greater risk.
Japanese and Taiwanese woman have one fifth the risk when compared to US women.
BRCA1 and BRCA2 mutations are associated with higher risk.
Ataxia telangiectasia heterozygotes are at 4-times increased risk.
Other pathology
Risk is increased with previous breast cancer, ovarian cancer, endometrial cancer, ductal carcinoma in situ, lobular carcinoma in situ, hyperplasia (unless mild), complex fibroadenoma, radial scar, papillomatosis, sclerosing adenosis, and microglandular adenosis.
Risk is decreased with cervical cancer.
Years menstruating
Factors increasing the number of menstrual cycles increase the risk, probably due to increased endogenous estrogen exposure.
Such factors include (1) nulliparity, (2) first full pregnancy when older than 30 years, (3) menarche when younger than 13 years (2 times the risk), (4) menopause when older than 50 years, and (5) not breastfeeding.
Obesity: Increased risk is probably due to adipose conversion of androgens to estrogens.
Socioeconomic class: Incidence is increased in individuals in a higher socioeconomic class.
Exogenous factors
Hormone replacement therapy increases risk (1.35 times for 10 y use, normalizing 5 y from discontinuing).
The use of oral contraceptive pills increases risk (1.24 times for 10 y use, normalizing 10 y from discontinuing). The progesterone-only pill is not associated with increased risk.
The use of diethylstilbestrol increases risk.
Alcohol consumption is associated with an increased risk, probably through increasing estrogen levels.
Irradiation, particularly in first decade of life, is associated with an increased risk of breast cancer.
Dichlorodiphenyldichloroethylene, a metabolite of the insecticide dichlorodiphenyltrichloroethane (DDT), exposure increases risk.
Exposure to some viral agents (eg, mouse mammary tumor virus) is associated with increased risk.
Other dietary, cultural, and/or geographic influences
High-risk regions include North America and northern Europe.
Low-risk regions include Japan and Hawaii; however, descendants migrating to the United States take on the higher US risk.
Clinical examination
Outline the following features in nonmedical terms when instructing a patient in breast self-examination. Explaining to the patient that the axillary tail must be included in the examination is important. Many patients are too anxious to examine their own breasts or find it too difficult, possibly because of generalized nodularity. In this situation, stressing the need of the patient to simply alert a clinician to any change in the breasts, particularly if the change persists through a complete menstrual cycle, is often easier. The following findings should raise concern:
Lump or contour change
Skin tethering
Nipple inversion
Dilated veins
Ulceration
Paget disease
Edema or peau d’orange
The nature of palpable lumps is often difficult to determine clinically, but the following features should raise concern:
Hardness
Irregularity
Focal nodularity
Asymmetry with the other breast
Fixation to skin or muscle
To detect subtle changes in breast contour and skin tethering, the examination must include an assessment of the breasts with the patient upright with arms raised. Assess fixation to muscle by moving the lump in the line of the pectoral muscle fibers with the patient bracing her arms against her hips. A complete examination includes assessment of the axillae and supraclavicular fossae, examination of the chest and sites of skeletal pain, and an abdominal and neurological examination.
August 15th, 2005
Breast cancer incidence
Breast cancer is one of the most important diseases for women in the United States and constitutes one fourth of all cancers in females, making it the most common cancer in females. Breast cancer develops in as many as 1 in 8 women by the time they are aged 80 years and is 100 times less common in men. Breast cancer accounts for approximately 15% of female cancer deaths. Approximately 182,800 new cases per year occur in the United States, causing 40,800 deaths per year. Breast cancer is the leading cause of death in women aged 44-50 years. The 5-year survival rate is 60% overall but is greater than 80% for early disease.
Approach to evaluation
As with all clinical conditions, approach breast cancer evaluation in the systematic way learned at the start of clinical training, namely with an ordered inquiry beginning with symptoms and general clinical history, followed by clinical examination and, finally, investigation, which can include imaging and ultimately biopsy. This approach naturally lends itself to a gradually increasing degree of invasiveness, so that when a diagnosis is obtained, the process can be stopped with the minimum amount of invasion and, consequently, minimum discomfort to the patient. Because the more invasive investigations also tend to be the most expensive, this approach is usually the most economical.
Evaluation goals
The aims of evaluation of a breast lesion are to judge whether surgery is required and, if so, to plan the most appropriate surgery. Therefore, the ultimate goal is to achieve the most appropriate degree of breast conservation while minimizing the need for reoperation.
Triple assessment
In breast cancer, the general approach to evaluation has become formalized as triple assessment, involving clinical examination, imaging (usually mammography and/or ultrasound), and needle biopsy, but always perform this as part of a more general assessment beginning with clinical history.
See more breast Cancer Information Here
August 15th, 2005
Background:
Small cell lung cancer (SCLC) is considered distinct from the other lung cancers, called non–small-cell lung cancers (NSCLCs), because of their clinical and biologic characteristics. SCLC exhibits aggressive behavior, with rapid growth, early spread to distant sites, exquisite sensitivity to chemotherapy and radiation, and frequent association with distinct paraneoplastic syndromes. Surgery usually plays no role in its management, except in rare situations (
August 3rd, 2005
Medical Care: Treatment options for the management of malignant mesothelioma include surgery, chemotherapy, radiation, and multimodality treatment.
Chemotherapy
Currently, cisplatin as a single drug had been used as the standard drug for phase III clinical trials. None of the standard treatment options has improved survival. The most active agents are anthracycline, platinum, and alkylating agents; each produces a response rate of 10-20%.
Vogelzang et al presented the results of a phase III study of pemetrexed in combination with cisplatin versus cisplatin alone. Pemetrexed (500 mg/m2/d) and cisplatin (75 mg/m2/d) or cisplatin (75 mg/m2/d) was given on day 1. Both arms were given every 21 days. The median time to survival in the cisplatin/pemetrexed arm was 12.1 months versus 9.3 months for cisplatin alone. The response rate was 41.3% for the cisplatin/pemetrexed arm and 16.7% for the cisplatin arm. Folic acid and vitamin B-12 were given routinely to prevent the adverse effects of pemetrexed. This trial established the regimen as the standard choice for this disease.
A 1999 phase II study by Byrne et al using cisplatin (100 mg/m2) on day 1 and gemcitabine (1000 mg/m2) administered intravenously on days 1, 8, and 15 of a 28-day cycle for 6 cycles showed response rates of 47.6% (complete and partial response), 42.8% (stable disease), and 9.5% (progressive disease). The median response duration was 25 weeks, progression-free survival was 25 weeks, and the overall survival was 41 weeks. Toxicity was mainly gastroenterologic and hematologic in nature.
Several other combinations have been found to be active, including cisplatin/doxorubicin (Adriamycin)/mitomycin C, bleomycin/intrapleural hyaluronidase, cisplatin/doxorubicin (Adriamycin), carboplatin/gemcitabine, and cisplatin/vinblastine/mitomycin C. The cisplatin/gemcitabine combination has yielded the best results.
With the isolation of mesothelial cell lines, several chemotherapeutic agents are being tested actively to assess their efficacy. One explanation for the poor response to chemotherapy is the low apoptotic rate, as evidenced by low BCL2 and BAX expression. These data suggest that apoptosis is not a key phenomenon in mesothelioma development and histologic differentiation.
Numerous trials of chemotherapeutic agents have been performed; however, until recently, the studies were small, the staging systems used were different, and the measurements of disease were inaccurate.
Radiation
Results with radiation therapy are also disappointing.
Radiation has no effect on survival, but it has caused significant palliation in 50% of patients treated for chest pain and chest wall metastasis.
Trimodality therapy
This involves a combination of all 3 standard strategies (ie, surgery, chemotherapy, radiation).
One trimodality approach involved extrapleural pneumonectomy followed by combination chemotherapy and radiotherapy. Overall survival rates were 45% at 2 years and 22% at 5 years.
Lymph node involvement was a significant negative prognostic factor. The epithelial type had a better survival rate compared with the sarcomatous or mixed type (65% vs 20% at 2 y and 27% vs 0% at 5 y).
Survival based on the Brigham staging system was 22 months for stage I, 17 months for stage II, and 11 months for stage III.
Overall median survival was 17 months, yielding a 2-year survival rate of 36% and a 5-year survival rate of 14%. Epithelial cell type survival was better, with a 2-year survival rate of 68% and 5-year survival rate of 46%.
Different chemotherapeutic regimens found to be useful in the trimodality treatment include cyclophosphamide/doxorubicin (Adriamycin)/cisplatin, carboplatin/paclitaxel, and cisplatin/methotrexate/vinblastine. External beam radiotherapy is delivered in a standard fractionation over 5.5-6 weeks.
Surgical Care: Surgical resection has been relied upon because radiation and chemotherapy have been ineffective primary treatments. The 2 surgical procedures used are pleurectomy with decortication and extrapleural pneumonectomy.
Pleurectomy with decortication is a more limited procedure and requires less cardiorespiratory reserve. It involves dissection of the parietal pleura, incision of the parietal pleura, and decortication of the visceral pleura followed by reconstruction. It has a morbidity rate of 25% and a mortality rate of 2%. It is a difficult procedure because the tumor encases the whole pleura; the local recurrence rate is high.
Extrapleural pneumonectomy is a more extensive procedure and has a higher mortality rate. Recently, the mortality rate has been lowered to 3.8%. It involves dissection of the parietal pleura; division of the pulmonary vessels; and en bloc resection of the lung, pleura, pericardium, and diaphragm followed by reconstruction. It provides the best local control because it removes the entire pleural sac along with the lung parenchyma.
With surgery alone, the recurrence rate is very high and most patients die after a few months. At least half the patients who have local control with surgery have distant metastasis upon autopsy.
Consultations:
If an infection is suggested initially, consultation with a pulmonary specialist is essential if the infection does not resolve within 2 weeks with adequate antibiotic treatment.
Chest radiographs are mandatory for follow-up if the infection has resolved. If the patient has diffuse calcification of the pleura and a history of weight loss with chronic cough, a full evaluation by a pulmonary specialist and oncologist is necessary.
A referral for thoracoscopy is warranted if the diagnosis is considered and the initial workup is not diagnostic.
Occupational history is important, and family members with exposure to asbestos should also be evaluated.
Diet:
Patients are usually cachetic after surgery, chemotherapy, and radiation. Good supportive care and a regular nutritional status assessment are warranted. Patients should be referred to a nutritionist.
Activity:
Beginning physical activity as soon as possible is important to prevent postoperative complications.
Pulmonary physiotherapy is very helpful because of the extensive lung resection in such patients.
August 3rd, 2005
History:
Dyspnea is the most common presenting symptom.
Chest x-ray films show obliteration of the diaphragm, nodular thickening of the pleura, decreased size of the involved chest, and/or radiolucent sheetlike encasement of the pleura.
A loculated effusion is present in more than 50% of patients, and a major portion of the pleura is opacified by the effusion.
Chest discomfort, pleuritic pain, easy fatigability, fever, sweats, and weight loss are the other common accompanying symptoms.
Approximately 60-90% of patients may have symptoms of chest pain or dyspnea.
Physical:
Physical findings of pleural effusion are usually noted upon percussion and auscultation.
In rare cases, malignant mesothelioma manifests as cord compression, brachial plexopathy, Horner syndrome, or superior vena cava syndrome.
Primary sites include the pleura (87%), the peritoneum (5.1%), the pericardium (0.4%), and the right side of the thorax (more so than the left side, by a ratio of 1.6:1)
Causes:
A substantial proportion of patients were exposed to asbestos in asbestos mills, shipping yards, mines, or their homes.
The crocidolite in asbestos is associated with mesothelioma in miners, manufacturers (using asbestos), and heating and construction workers.
Malignant mesothelioma has also been linked to therapeutic radiation using thorium dioxide and zeolite, a silicate in the soil.
An etiological role for simian virus 40 in malignant mesothelioma has also been suggested.
Interleukin 8 has direct growth-potentiating activity in mesothelial cell lines.
August 3rd, 2005
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