Elsevier

PET Clinics

Volume 6, Issue 3, July 2011, Pages 275-297
PET Clinics

Multimodality Imaging Review of Malignant Pleural Mesothelioma Diagnosis and Staging

https://doi.org/10.1016/j.cpet.2011.04.001Get rights and content

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Clinical presentation of malignant pleural mesothelioma

Symptoms of MPM are nonspecific and include dyspnea, chest pain, systemic symptoms of malignancy, or combinations of these. The type of chest pain may be pleuritic and/or neuropathic, due to involvement of autonomic, brachial, or intercostal nerves by tumor. Although dyspnea is commonly related to a pleural effusion at diagnosis, as the disease progresses it is often due to the restrictive respiratory effects of pleural thickening. As the disease advances, symptoms of cardiac tamponade may

Staging systems for malignant pleural mesothelioma

The pattern of MPM invasion is first locoregional with the disease manifesting as small plaques on the parietal pleura, resulting in diffuse thickening and subsequent fusion of the pleurae, which eventually leads to encasement and possible compression and/or invasion of the ipsilateral lung. Nodal involvement is not infrequent, and as the tumor grows, the chest wall, mediastinal organs, contralateral lung, diaphragm, and peritoneum may become involved.

Defining the extent of disease at the time

Implications of stage and treatment selection in malignant pleural mesothelioma

The implications of stage on treatment selection depend entirely on whether surgical intervention will be a treatment possibility for the individual. In patients who have performance status or comorbidities precluding surgery, who specifically decline surgery, or for whom surgery is geographically unavailable, stage is arguably unimportant in treatment selection, with the choice of symptom palliation or systemic chemotherapy being unaffected by anatomic location of tumor or presence of

Indications for mediastinoscopy and endobronchial ultrasonography for staging of malignant pleural mesothelioma

PET/computed tomography (CT) has substantial limitations in staging nodal disease,26, 27, 28 and CT imaging does not perform any better.29 Because of this, there are advocates for routine surgical staging by mediastinoscopy in all patients prior to surgical resection.29, 30 However, further small surgical series suggest that negative mediastinoscopy has poor predictive value for N2 involvement and patient outcomes.31

Newer techniques such as endobronchial ultrasonography (EBUS) and esophageal

Role of multimodality imaging in the diagnosis and staging of malignant pleural mesothelioma

Early diagnosis and an accurate disease staging in patients with MPM are essential in classifying them into prognostic subgroups to allow delivery of stage-specific therapies, or to carry out the necessary steps to improve their quality of life.

Local control of the disease improves following prompt diagnosis, accurate staging, and trimodality therapy.23 Unfortunately, the noninvasive selection of patients who could benefit from therapy still remains a diagnostic challenge. Cytologic examination

Benign versus malignant pleural disease

Functional imaging with FDG-PET has come of age with today’s practice of oncology because of the technique’s inherent capacity to interrogate tumoral biological behavior and metabolism noninvasively, without reliance solely on lesion size and shape to characterize a lesion as being benign or malignant. In addition, the information gathered by whole-body PET images enhances findings observed on conventional imaging modalities during the diagnosis, preoperative staging, and postoperative

Preoperative staging

The imprecise anatomic detail of FDG images and their low spatial resolution, coupled to the irregular, nonspherical growth and invasion patterns of MPM, make T staging challenging with PET. Although earlier studies using dedicated PET scanners and coincidence gamma cameras showed good agreement between FDG and surgical findings, and that in many cases the metabolic images correctly predicted unresectable disease, they also brought to the surface some of the limitations of the technique.53, 54,

Postoperative restaging and PET/CT patterns of recurrent MPM

MPM recurrence can present as locoregional and/or distant disease. Depending on the type of treatment algorithm used, local recurrence rates have been reported to range from 12% to 88%, and distant failure rates from 9% to 100% of cases.76, 78, 79 Local recurrence tends to be more common following P/D, whereas a combination of local and distant failure is found following EPP.76, 79

Baldini and colleagues76 reported a median time to first recurrence of 20 months in patients treated with

Standard Uptake Value

The fact that FDG uptake in primary pleural lesions is a function of the number of cancer cells, cellular proliferation, and the expression of GLUT receptors, all of which have been correlated with poor outcome in other thoracic tumors (eg, lung cancer, esophageal cancer), has led investigators to study the prognostic value of FDG uptake in MPM.

Bénard and colleagues83 published the first study addressing the prognostic value of FDG-PET in MPM patients. In 17 patients with histologically

Pleurodesis

Talc pleurodesis is commonly performed in patients with MPM for palliation of recurrent pleural effusions.89, 90 Talc induces an intense inflammatory reaction in pleura, resulting in chronic fibrosis.91 The inflammatory effects of pleurodesis are evident on FDG-PET imaging and may persist for years.92 The effect of talc pleurodesis on staging with CT or FDG-PET has not been well described. A recent study, however, suggests that talc pleurodesis may influence both CT and FDG-PET imaging. In a

Novel PET probes

Novel PET radiotracers have been developed that may potentially allow the imaging of a variety of biological processes in mesothelioma. 3′-Deoxy-3′-[18F]fluorothymidine (FLT) is a thymidine analogue, and as such a marker of cellular proliferation. FLT is transported into the cell and phosphorylated by thymidine kinase 1 (TK1), but not incorporated into DNA. Preclinical studies suggest that mesothelioma is a proliferative tumor and is likely to demonstrate FLT activity on PET imaging.94 This

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