Meeting reportCurrent state and future directions of pleural mesothelioma imaging
Introduction
Radiologic imaging is essential to the diagnosis, staging, and clinical management of patients with malignant pleural mesothelioma. X-ray imaging techniques (chest radiography and computed tomography (CT)), magnetic resonance (MR) imaging, positron emission tomography (PET), and, most recently, multimodality PET/CT all have been used to evaluate this disease, although the relative importance of these imaging modalities has changed over time. Imaging-based studies presented at the 8th International Conference of the International Mesothelioma Interest Group (IMIG) in October 2006 sought to further define the current practice and future potential of radiology for the mesothelioma patient. The intent of this communication is to highlight the imaging research reported at the 2006 IMIG Conference, to frame this research in the context of the unique imaging challenges presented by mesothelioma, and to stimulate dialogue on future resolution of these challenges.
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Clinical applications and challenges
Malignant pleural mesothelioma is a tumor of the pleural lining of the lung. A large majority of patients will die within a year of diagnosis, and only a very small minority will survive 5 years. Mesothelioma has a very strong association with exposure to asbestos and is exceedingly rare in its absence. The geographic incidence is linked with the pattern of use of asbestos and any subsequent ban. Mesothelioma in Western Europe is predicted to rise to 9000 deaths per annum in around 2018, with a
Tumor measurement and response assessment
The acquisition and comparison of temporally sequential imaging studies is standard practice for the evaluation of tumor response. While CT is the dominant study for this application, complementary roles are being developed for other imaging modalities. CT provides essential information on tumor morphology at any one time point so that CT-based response may be assessed on the basis of change in morphology between multiple time points. “Morphology” broadly encompasses lesion “shape,” which is a
PET/CT in staging
The primary imaging modality used in the staging of mesothelioma is CT [19], [20], which is usually performed to assess the extent of chest wall, mediastinal, and diaphragmatic invasion and the presence or absence of nodal and distant metastases [21], [22]. In the preoperative staging evaluation of patients with mesothelioma, contrast-enhanced magnetic resonance imaging (MRI) may be used to address equivocal findings on CT concerning the local extent of tumor. The marked enhancement of this
Computer model for volumetric response assessment
Clinically reliable quantification of mesothelioma extent is challenging. As previously discussed, recent studies have reported the inadequacy of the unidimensional RECIST criteria for assessing therapy response in mesothelioma. Although tumor volume in mesothelioma has been shown to correlate with patient survival better than tumor thickness [42], the lack of automated or semi-automated tools to quantify tumor volume prevents further validation of this correlation and hinders clinical use of
Molecular imaging of mesothelioma
Improved imaging techniques are needed for more accurate assessment of disease extent, evaluation of treatment response, and better matching of patient and treatment in the setting of clinical trials for mesothelioma [45]. Improved imaging also would permit more accurate, targeted drug delivery and better adjuvant radiotherapy planning. Anatomic imaging modalities such as CT and MRI have been used to assess total tumor burden in the course of treatment. The identification of residual viable
Conclusion
The diagnosis, staging, and response assessment of mesothelioma pose unique challenges to radiologic imaging. No single, conventional imaging approach captures the information necessary to direct all aspects of patient management. Instead, the complexities of this unique disease demand the integration of elements cleverly adapted from different modalities.
CT is currently the primary modality for the diagnosis, staging, and response assessment of mesothelioma, although CT has definite
Acknowledgments
The authors gratefully acknowledge the International Mesothelioma Interest Group (IMIG) and all those who contributed to the 8th International Conference. SA would like to thank Dr. Heber MacMahon and Dr. Geoffrey Oxnard. AN acknowledges other investigators on the study at Sir Charles Gairdner Hospital, including Dr. Roslyn Francis, Dr. Michael Byrne, Dr. Agatha van der Schaaf, Dr. Jan Boucek, and Dr. Michael Phillips. BZ would like to acknowledge other investigators on the study at Memorial
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