Diagnostico clínico y estadiaje del mesotelioma asbesto

Diagnostico clínico y estadiaje del mesotelioma asbesto

• 1.
  DIAGNÓSTICO CLÍNICO Y ESTADIAJEDEL MESOTELIOMA-ASBESTO DR. JORDI ROIG Neumología
• 2.
  Clinical Features ofMalignant Mesothelioma Age 40-70 y Male-to-female ratio 5:1 Risk factors Asbestos exposure, eg, shipyard workers, miners Spouse of asbestos worker Irradiation Beryllium exposure Latency period after asbestos exposure 30-45 years Type of asbestos fiber Crocidolite  amosite > tremolite > chrysotile Incidence Nonasbestos exposure—1:1,000,000 Asbestos exposure—0.2-2:100 History of asbestos exposure 13%-76% Smoking history 36%-71% Symptoms to diagnosis <6 mo 70% >6 mo 28% Survival without treatment (after diagnosis) 6.8-15 mo
• 3.
  Reference Sex ExposureAge at exposure Age at diagnosis Dahlgren, 1967 F Thorotrast 23 36 Brody et al, 1977 M Hodgkin's disease 29 34 Brenner et al, 1982 M Hodgkin's disease 27 34 Antman et al, 1984 M Wilms' tumor 3 44 Antman et al, 1984 M Wilms' tumor 6 22 Antman et al, 1984 F Breast cancer 30 40 Antman et al, 1983 F RT to neck scar 29 55 Tester et al, 1984 M Hodgkin's disease 23 28
• 4.
  Reference Sex ExposureAge at exposure Age at diagnosis Anderson et al, 1985 M Wilms' tumor 2 16 Austin et al, 1986 F Wilms' tumor 4 24 Kawashima et al, 1990 F Breast cancer 34 64 Lerman et al, 1991 F Hodgkin's disease 4 24 Hoffman et al, 1994 F Hodgkin's disease 13 22 Shannon et al, 1995 F Breast cancer 65 75 Shannon et al, 1995 F Breast cancer 39 74 Weissman et al, 1996 M Hodgkin's disease 32 46 Weissman et al, 1996 M Hodgkin's disease 7 33
• 5.
  Cugell, D. W.et al. Chest 2004;125:1103-1117 The latent period: pleural changes in 624 asbestos-exposed industrial employees
• 6.
  PATOLOGÍA RESPIRATORIA RELACIONADA CONASBESTO ASBESTOSIS PULMONAR (FIBROSIS) PATOLOGÍA PLEURAL ASBESTO Y CÁNCER DE PULMÓN PLACAS PLEURALES DERRAME BENIGNO MESOTELIOMA
• 8.
  PLACAS PLEURALES MESOTELIOMA PATOLOGÍAPLEURAL PATOLOGÍA RESPIRATORIA RELACIONADA CON ASBESTO
• 9.
  Clinical Presentation ofMalignant Pleural Mesothelioma (MPM)  Symptoms Observed in Most Patients  Chest pain  Shortness of breath  Weight loss  Other Symptoms  Cough  Hoarseness  Fever  Sweats
• 10.
  Clinical Presentation ofMPM  Physical Examination  Asymmetric chest excursion  Unilaterally decreased breath sounds  Laboratory Findings  Laboratory studies are generally not useful in disease diagnosis. However, leukocytosis, anemia, thrombocytosis, and elevated LDH are commonly observed. Cancer: Principles and Practices of Oncology, 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2001:1943-1969.
• 18.
  PLACAS ASBESTÓSICAS +DERRAME: ¡¡ESTUDIAR!!
• 19.
  Adams, R. F.et al. Chest 2001;120:1798-1802 Contrast-enhanced chest CT showing a large pleural nodule
• 22.
  Differential Diagnosis ofMPM Often misdiagnosed Adenocarcinoma may mimic epithelial presentation Adenocarcinomas from primary lung, breast, stomach, kidney, ovary, and prostate cancers metastasizing to the lung pleura can resemble mesothelioma Examination of pleural fluid or BCN-FNA aspirates may aid differential diagnosis
• 23.
  MESOTELIOMAS Y SEUDOMESOTELIOMAS
• 24.
  MESOTELIOMA vs SEUDOMESOTELIOMA
• 27.
  PLACAS ASBESTÓSICAS “SOSPECHOSAS”:¿MESOTELIOMA? En caso de duda: PLANTEAR TORACOSCOPIA
• 28.
  MESOTELIOMA EN MUJERSIN RELACIÓN CONOCIDA CON ASBESTO
• 29.
  DISTINTOS ASPECTOS ENDOSCÓPICOS DELMESOTELIOMA PLEURAL MALIGNO PLACAS ASBESTÓSICAS + MESOTELIOMA (EXPOSICIÓN AAMIANTO>30 AÑOS) NÓDULOS DIFUSOS (EXPOSICIÓN AAMIANTO: 18 AÑOS)
• 30.
  Soluble mesothelin-related protein –A blood test (MM)  Sensitivity 83% (n=48) and specificity 100% when compared to other effusions  With lung tumors: ↓ specificity to 95%  Other asbestos exposed: ↓ specificity to 82%  May be increased prior to presentation  Seven of 40 healthy asbestos exposed had ↑ levels and 3 developed MM at 1-5 years  None of other 33 exposed developed MM<8 years Robinson B et al. Lung Cancer 2005
• 32.
  Brigham/Dana Farber CancerInstitute staging of malignant pleural mesothelioma The Revised* Brigham/DFCI Staging System for Malignant Pleural Mesothelioma Stage Description I Disease completely resected within the capsule of the parietal pleura without adenopathy; ipsilateral pleura, lung, pericardium, diaphragm, or chest wall disease limited to previous biopsy sites II All of stage I with positive resection margins and/or intrapleural adenopathy III Local extension of disease into the chest wall or mediastinum, into the heart or through the diaphragm, into the peritoneum, or with extrapleural lymph node involvement IV Distant metastatic disease *Patients with Butchart stage II or III disease are combined into stage III. Stage I represents patients with resectable disease and negative nodes. Stage II indicates resectable disease but positive nodes.
• 33.
  Cugell, D. W.et al. Chest 2004;125:1103-1117 Mesothelioma
• 34.
  Stage Description T1A Tumor limited to the ipsilateral parietal pleura, including mediastinal and diaphragmatic pleura. No involvement of the visceral pleura T1B  Tumor involving the ipsilateral parietal pleura, including mediastinal and diaphragmatic pleura. Scattered foci of tumor also involving the visceral pleura T2  Tumor involving each of the ipsilateral pleural surfaces (parietal, mediastinal, diaphragmatic, and visceral pleura) with at least one of the following features:  Involvement of the diaphragmatic muscle  Confluent visceral pleural tumor (including the fissures) or extension of tumor from visceral pleura into the underlying pulmonary parenchyma New International Mesothelioma Interest Group (IMIG) Staging System Chest 1995;108:1122-1128.
• 35.
  Stage Description T3 Tumor involving each of the ipsilateral pleural surfaces (parietal, mediastinal, diaphragmatic, and visceral pleura) with at least one of the following features:  Involvement of the endothoracic fascia  Extension into the mediastinal fat  Solitary, completely resectable focus of tumor extending into the soft tissues of the chest wall  Nontransmural involvement of the pericardium New International Mesothelioma Interest Group (IMIG) Staging System (cont’d) Chest 1995;108:1122-1128.
• 36.
  Stage Description T4  Locallyadvanced technically unresectable tumor  Tumor involving all of the ipsilateral pleural surfaces (parietal, mediastinal, diaphragmatic, and visceral pleura) with at least one of the following features:  Diffuse extension or multifocal masses of tumor to the peritoneum  Direct transdiaphragmatic extension of tumor to the peritoneum  Direct extension of tumor to the contralateral pleura  Direct extension of tumor to one or more mediastinal organs  Direct extension of tumor into the spine  Tumor extending through to the internal surface of the pericardium with or without a pericardial effusion; or tumor involving the myocardium New International Mesothelioma Interest Group (IMIG) Staging System (cont’d) Chest 1995;108:1122-1128.
• 37.
  Stage Description N: LymphNodes  Regional lymph nodes cannot be assessed  No regional lymph node metastases  Metastases in the ipsilateral bronchopulmonary or hilar lymph nodes  Metastases in the subcarinal or the ipsilateral mediastinal lymph nodes, including the ipsilateral internal mammary nodes  Metastases in the contralateral mediastinal, contralateral internal mammary, ipsilateral, or contralateral supraclavicular lymph nodes  Presence of distant metastases cannot be assessed  No distant metastases  Distant metastases present NX N0 N1 N2 N3 M: Metastases MX M0 M1 New International Mesothelioma Interest Group (IMIG) Staging System (cont’d) Chest 1995;108:1122-1128.
• 38.
  Stage Description Ia T1aN0M0 T1bN0M0 IIT2N0M0 III Any T3M0 Any N1M0 Any N2M0 IV Any T4 Any N3 Any M1 Ib Interest Group (IMIG) Staging System
• 39.
  Accuracy of malignantpleural mesothelioma
• 42.
  Investigations Including Confirmatory tests Demographics Genderand age Clinical history Performance status, presence/absence of chest pain, dyspnea, change in body weight or BMI* As appropriate Physical examination “Presence or absence of shrinking hemithorax” As appropriate Radiological investigations Chest X-ray: PA/lateral in-/expiration, pre-/post drainage of pleural fluid Blood tests Hemoglobin, leucocytes, platelets, basic biochemistry van Meerbeeck JP. Lung Cancer May 2005 Step I, to be considered in all patients at presentation or diagnosis
• 43.
  Investigations Including Confirmatory tests CT scanof chest and upper abdomen Spiral technique, with iv contrast, including lowest costophrenic angles, after drainage of pleural fluid Pulmonary function tests Forced vital capacity (FVC), forced expiratory volume 1 sec (FEV1) Bone scan Not routine, to be considered on clinical suspicion only Standard X- ray or CT/MRI to confirm dubious findings Brain CT/MRI Not routine, to be considered on clinical suspicion only Step II, to be considered in patients being candidate for any kind of active treatment
• 44.
  Índice modificado deGoldman de riesgo operatorio en cirugía no cardiaca Edad >70 años 5 Infarto agudo de miocardio en los 6 meses anteriores 10 Galope S3, Ingurgitación yugular, Fracción de eyección < 40% 11 Estenosis aórtica importante 3 Ritmo no sinusal o extrasistolia auricular 7 >5 complejos ventriculares prematuros por minuto 7 P02<60 mm Hg ; PCO2>50 mm Hg ; HCO3<20 3 Mala situación clínica general: creatinina > 3, hepatopatía, encamado. 3 Grado I (0-5 puntos): riesgo bajo; Grado II (6-12 puntos): riesgo intermedio; Grado III (13-25 puntos) y grado IV (>26 puntos): riesgo alto
• 45.
  Area Investigation Patientgroup Confirmatory tests Diaphragm Chest X-ray, in-/expiration Every patient considered for radical treatment Fluoroscopy Extrathoracic excluding “occult” M1 Full ring FDG-PET scan Every patient considered for radical treatment Biopsy of suspected extrathoracic lesions Laparoscopy Institutional practice Mediastinum, excluding T4, N2/3 Cervical mediastinoscopy, VATS, contralateral VATS Institutional practice Chest MRI Gadolinium enhanced EUS-FNA / PET -CT Investigational Step III: to be considered only in patients being candidate for radical treatment
• 46.
  The consensus panelfurther agrees on that: 1. The interval within which the assessment has to be finalized should be as short as possible. 2. Recent (<1-month-old) imaging studies should be available prior to invasive procedures. 3. Further research is done with regard to the comparative efficacy of the different intrathoracic techniques (mediastinoscopy, VATS, EUS-FNA) and the value of the newer ones (PET-CT, EUS- FNA).
• 47.
  Monnet, I. etal. Chest 2002;121:1921-1927 Chest radiograph with the implantable port related to the pleural catheter