decompression are improvements in gas exchange, venous return to the thorax, cardiac output, and arterial blood pressure.
Malignant mesothelioma
Unlike primary lung cancer (discussed in Chapters 20 and 21), malignant mesothelioma is a malignant neoplasm that primarily involves the pleura rather than the airways or the pulmonary parenchyma. Malignant mesothelioma is relatively uncommon compared to lung cancer, and unlike lung cancer, smoking is not a risk factor. The primary risk factor for development of malignant mesothelioma is a history of exposure to asbestos, generally in the range of 30 to 40 years earlier. Individuals who have worked in the types of jobs that expose them to asbestos (see Chapter 20) are the persons at highest risk, but a heavy exposure is not necessary to increase the risk for malignant mesothelioma. In fact, mesothelioma develops in spouses of asbestos workers, presumably because of inhalation of asbestos dust while exposed to their partners’ clothes.
In patients with malignant mesothelioma, the main symptoms are chest pain, dyspnea, and sometimes cough. Chest imaging studies are most notable for the presence of pleural fluid and often irregular or lobulated thickening of the pleura (Fig. 15.10). Diagnosis requires biopsy of the pleura and histologic demonstration of the malignancy. Because the tumor originates in the pleura and does not directly communicate with airways, malignant cells are not shed into the tracheobronchial tree and cannot be found on cytologic examination of sputum or bronchoscopy specimens.
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FIGURE 15.10 Chest radiograph of patient with mesothelioma. Note several
lobulated, pleural-based masses in right hemithorax accompanied by right pleural
effusion.
Mesothelioma is suggested by pleural fluid, irregular or lobulated pleural thickening, and a distant history of asbestos exposure.
The prognosis for malignant mesothelioma is poor. The tumor eventually entraps the lung and spreads to mediastinal structures. Death generally results from respiratory failure. No clearly effective form of therapy is available, and fewer than 10% of patients survive 3 years. Although improved mortality has not been demonstrated in randomized trials, surgical approaches to treatment have included unilateral removal of the visceral and parietal pleura and any visible tumor (called pleurectomy and decortication), or unilateral removal of the pleura and visible tumor as well as removal of the entire ipsilateral lung (called extrapleural pneumonectomy). Chemotherapy and/or radiotherapy have also been used, either alone or in combination with one of the surgical options. As a palliative measure for patients with persistent symptomatic pleural effusions, obliteration of the pleural space (pleurodesis) with a sclerosing agent can be performed in an attempt to prevent reaccumulation of large amounts of pleural fluid. Because of the poor prognosis, mesothelioma has become a target for a variety of new types of investigational therapy, including immunotherapy using immune checkpoint inhibitors, cellular therapy using genetically engineered T lymphocytes, and therapy aimed at specific molecular targets.
Suggested readings
General reviews
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Pleural effusion
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Reddy C.B, DeCamp M.M, Diekemper R.L, Gould M.K, Henry T, Iyer N.P., et al. Summary
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for clinicians: Clinical practice guideline for management of malignant pleural effusions
Annals of the American Thoracic Society 2019;16: 17-21.
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Pneumothorax
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Malignant mesothelioma
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Woolhouse I, Bishop L, Darlison L, De Fonseka D, Edey A, Edwards J., et al. British Thoracic Society guideline for the investigation and management of malignant pleural mesothelioma Thorax 2018;73: i1i30.
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