Transcript Mesothelioma

Mesothelioma
• Is a malignant tumour of pleura, usually
resulting from asbestos exposure. Asbestos is
the major single cause and there is a history of
occupational asbestos exposure in up to 90%
of cases.
• Mean latent interval between the 1st exposure
and death is around 40 years. There is no
significant association with smoking.
• Clinical features
- Chest pain usually dull in nature , diffuse , and
occasional.
- Breathlessness and it is progressive.
- Clubbing may occur but it is rare.
- Pleural effusion is common presentation.
• Investigations
- Pleural fluid aspiration, reveals exudative ,
straw coloured or bloody effusion. Cytological
analysis rarely provide the diagnosis, (
sensitivity is around 32% ).
- Imaging ( CXR, CT chest), features include;
1- moderate to large effusion
2- plural mass or thickening
3- local invasion
4- pleural plaque or pulmonary fibrosis.
• Treatment
- Management or pleural effusion by repeated
aspiration and Talc pleurodesis.
- Radiotherapy , prophylactic radiotherapy
greatly reduce chest wall invasion.
- Surgery , very limited use
- Chemotherapy , the role is still unclear and
under researches.
- Median survival is varies between 8-14
months.
• Pneumothorax
Is air in the plural space , may occur with
apparently normal lung ( primary
pneumothorax), or in the presence of
underline lung disease ( secondary
pneumothorax). It could occur spontaneously
or result from iatrogenic injury to the lungs or
chest wall.
The primary form principally affects male aged
15-30 years, they are usually tall , thin and
smokers.
• Calssification
l- spontaneous
A- primary pneumothorax; Without evidence of
lung disease, air escape from the lung in to
the pleural space through rupture of a small
emphysematous bulla or pleural blep.
B- secondary pneumothorax; there is underline
lung disease , most commonly , COPD, TB,
asthma, lung abscess , ca bronchus and
interstitial lung diseases.
II- Iatrogenic , or traumatic following surgery or
biopsy ,
• Clinical features;
- Sudden onset pleuretic chest pain
- SOB , in those with underline lung disease ,
the SOB may be so severe.
- Clinical signs may be absent in small
pneumothorax, but in large pneumothorax
when > 15% of hemi thorax involved it might
result in decrease or absent breath sound on
auscultation. The combination of absent
breath sound and hyper resonant percussion
note is diagnostic of pneumothorax.
• Types of spontaneous pneumothorax
1- closed type; when there is no communication
between the lung and pleural space (
communication seal off), here the pleural
pressure is negative.
2- open , when the communication between the
lung and pleural space fails to seal off , the
pleural pressure will be atmospheric.
3- Tension type, large amount of air accumulates
in the pleural cavity and mean pleural
pressure will be positive.
• The positive pressure causes mediastinal
displacement towards the opposite side , with
compression of the opposite normal lung
causing cardio- respiratory compression.
( Tension Pneumothorax)
• Investigations
- CXR, shows the sharply defined edge of
deflated lung with complete translucency ( no
lung marking), between the lung edge and
the chest wall.
- CT chest is useful to differentiate
emphysematous bullae from pneumothorax
• Management
l- primary pneumothorax;
- When the distance between the lung edge
and the chest wall is < 2cm and the patient
not SOB it will normally resolve with out
intervention.
- When the distance is > 2cm and the patient
symptomatic , percutaneous needle aspiration
is well tolerated procedure of choice with 6080% chance of avoidance the need of
Intercostal chest drain.
- Failure of needle aspiration . Required
intercostal chest drain insertion, and it should
be inserted in 4th – 6th intercostal space in
mid- axillary line.
ll – secondary pnemothorax
Even small secondary pneumothorax may cause
respiratory failure , hence all patients required
intercostal chest drain insertion.
• Recurrent pneumothorax required surgical
intervention in the form of either surgical
pleurodesis or pleurectomy.
• Patient with tension pneumothorax required
urgent intervention to relieve the pressure by
insertion of a needle in to the 2nd intercostal
space , mid clavicular line of the affected site.
• All patients with pneumothorax should
receive high concentration oxygen therapy, as
this accelerate the rate that the air will be
absorbed by pleura.
• Smoking sessation advise should be given to
every one with pneumothorax.