Pleural Disease Flashcards
(22 cards)
What are the causes of mesothelioma?
- Asbestos (90%)
- All types, amphibole most potent
- Mean interval time from 1st exposure to death = 40 years
- Not dose-related
- Non-asbestos fibres
- Erionite (found in rocks in Cappadocia, Turkey)
- Simian Virus 40 (contaminate Polio vaccine in the 50s-60s
- Ionizing radiation, chest trauma (both rare)
What are the common investigations for mesothelioma and their findings?
- Pleural Fluids
- Appearance: exudative straw coloured or bloody
- Cytology sensitivity 32-84% (poor for diagnosing sarcomatoid mesothelioma)
- Low pH and glucose in extensive tumours
- Avoid repeat aspirations due to risk of tracking
- CXR/CT
- Effusion
- Pleural nodularity or enhancement (following pleural contrast)
- Involvement of mediastinal pleura
- Localised pleural mass/thickening with no effusion
- Uniform encasement of lung –> small hemithorax
- Local invasion (chest wall, mediastinum, ribs, heart, hilar nodes, diaphragm/transdiaphragm
- Biopsy
- US/CT guided/thoracoscopic much better yield than blind Abram’s)
What are the histological subtypes of mesothelioma?
- Epithelioid – 50% of cases, often confused with adenocarcinoma, better prognosis)
- Sarcomatoid (or Fibrous) – includes lymphohistocytoid and desmoplastic patterns, worse prognosis
- Mixed
What are the features of a T1 tumour?
Limited to the ipsilateral pleura
What are the features of a T2 tumour?
Limited to the ipsilateral pleura with limited local invasion to (DL)
2a Diaphragm
2b Lung
What are the features of a T3 tumour?
Locally advanced resectable disease with moderate local invasion (FFCP)
3a Endothoracic fascia
3b Mediastinal fat
3c Chest wall (resectable)
3d Outer pericardium
What are the features of a T4 tumour?
Locally advanced unresectable disease with advanced local invasion (CPPMSM)
4a Diffuse/multifocal chest wall
4b Peritoneum
4c Contralateral pleura
4d Mediastinal organs
4e Spine
4f Extension through mediastinum/pericardial effusion/myocardial tumour
What are the features of N1 disease?
Ipsilateral bronchopulmonary/hilar/mediastinal LN involvement
What are the features of N2 disease?
Contralateral mediastinal or an supraclavicular LN involvement
What are the stages of mesothelioma for the following:
- T2N2M0
- T1N0M0
- T4N1M0
- T2N2M1
- T1N1M0
- T4N1M0
- T2N1M0
- T2N0M0
- T3N1M0
- Stage IIIB
- Stage IA
- Stage IIIB
- Stage IV
- Stage II
- Stage IV
- Stage II
- IB
- IIIA
What are the 5 year survival rates for different stages of mesothelioma?
IA = 15%
IB = 13%
II = 10%
IIIA = 8%
IIIB = 5%
IV = 0%
What are the median survival rates for different stages of mesothelioma?
IA = 24m
IB = 20m
II = 19m
IIIA = 14m
IIIB = 14m
IV = 10m
How can malignant effusions be managed in mesothelioma?
- Early definitive treatment – avoid repeat aspirations
- Talc pleurodesis (chest drain or thoracoscopy) – avoid if lung does not re-expand/trapped lung
- IPC
What are the management options in mesothelioma?
- General
- Early involvement of pain team and palliative care
Opitates/NSAIDs for chest wall pain
Amitriptyline/gabapentin/pregabalin for neuropathic pain
Multifactorial management of dyspnoea - Compensation
- Requires coroner referral
- Radiotherapy
- Palliative radiotherapy – useful for pain, no benefit for dyspnoea/SVCO/tract prevention
- Surgery
- Thoracoscopy with pleurodesis
- Partial pleurectomy (no benefit over talc pleurodesis)
- Pleurectomy with to decortication
- Extended pleurectomy with decortication (EPD) – lung sparing with complete macroscopic resection including diaphragm/pericardium – not recommended unless clinical trial
- Extrapleural pneumonectomy (EPP) – not recommended by BTS
- SAAC
- Pemetrexed + cisplatin - improves median survival by 3 months
What are some of the legalities in asbestos-related compensation?
- Not available if self-employed
- Governmental Compensation
o Available for: DPT (diffuse pleural thickening), asbestosis, lung cancer associated with DPT or asbestosis, mesothelioma
o Amount reflects level of disability at age of diagnosis (£14k-£92k)
o NOK can apply within 12 months posthumously (but receive less)
o Benefits available for those with secondary exposure (from partner) and self-employed - Civil Court Compensation
o Compensation directly from previous employer – claimed from employee’s insurer, even if no longer in existence
o Claim must be made within 3 years of patient’s awareness of diagnosis
o Pleural plaques compensable in N. Ireland and Scotland only
What aetiologies are associated with the following characteristics of pleural aspirates?
Bloody
Turbid/milky
Viscous
Food particles
Bile-stained
Black
Brown
Urine odour
Putrid odour
Bloody- Trauma, malignancy, pulmonary infarct, pneumonia, post-cardiac injury syndrome, pneumothorax, benign asbestos-related pleural effusion, aortic dissection/rupture. Haemothorax defined by haematorcrit >50% of peripheral blood
Turbid/milky- Empyema, chylodthorax, pseudochylothorax
Viscous- Mesothelioma
Food particles- oesophageal rupture
Bile-stained- cholothorax (biliary fistula)
Black- Aspergillus, metastatic melanoma
Brown - Amoebic liver abscess
Urine odour - Urinothorax
Putrid odour - Anaerobic empyema
What aetiologies are associated with the following predominant cell type in pleural aspirates?
Neutrophils
Mononuclear cells
Lymphocytes
Eosinophils
Mesothelial cells
Lupus Erythematosus Cells
Neutrophils - Any acute effusion (parapneumonic, PE)
Mononuclear cells- Any chronic effusion (malignancy, TB)
Lymphocytes - TB (especially if >80%), cardiac failure, malignancy, sarcoidosis, lymphoma, RA, post-CABG, chylothorax
Eosinophils - Often unhelpful, associated with blood and air in the pleural space. Also malignancy and infection
Mesothelial cells - Predominant in transudates. Often supressed in inflammatory conditions (TB). Atypical suggests mesothelioma
Lupus Erythematosus Cells - SLE
What are the causes of malignant pleural effusions?
- Lung (40%)
- Breast (15%)
- Lymphoma (10%)
- Mesothelioma (10%)
- Genitourinary (10%)
- GI (5%)
- Unknown (10%)
What are the common types of asbestos including where they are typically found?
Serpentine asbestos
* Most common (95%)
* Chrysotile (white asbestos) is the only type
* Commonly found: roofs, ceilings, walls, floors, brake linings, boiler seals, pipe insulation
Amphibole asbestos
* Much more potent
* Common types:
- Amosite (brown) asbestos
Commonly found: cement sheets, pipe insulation
- Crocidolite (blue) asbestos
Commonly found: steam engines
What is SFTP and how is it managed?
Solitary Fibrous Tumours of the Pleura (SFTP)
* Pleural fibroma
* Rare tumour
* Usually benign, can be malignant
* Management – surgical resection
Describe the aetiology, appearance, diagnostic criteria and causes of a chylothorax
Aetiology: disruption of the thoracic duct
Appearance: turbid/milky/serous/bloodstained
Diagnosis: presence of chylomicrons, triglycerides >1.24
Cause: trauma/post-thoracotomy, malignancy (especially lymphoma), pulmonary LAM (lymphangioleiomyomatosis), TB
Describe the aetiology, appearance, diagnostic criteria and causes of a pseudochylothorax
Pseudochylothorax
Aetiology: cholesterol crystal deposition in chronic effusion
Appearance: milky
Diagnosis: cholesterol >5.17, cholesterol crystals at polarized light microscopy
Cause: RA pleurisy, TB
