This document summarizes research on malignant mesothelioma conducted in Egypt between 1996-2003. Some key findings include: - Mesothelioma primarily affects the pleura and is strongly linked to asbestos exposure, especially from industries like mining and shipbuilding. - The study analyzed 747 Egyptian patients with mesothelioma and found the highest rates in industrial areas, affecting younger groups than other countries. - The majority of cases were epithelial type with symptoms like dyspnea and chest pain. Diagnosis was usually by biopsy and prognosis was poor even with treatment. - Recommendations included preventive measures to reduce asbestos pollution and relocating factories using asbestos away from residential areas.

1. ‫الرحيم‬ ‫الرحمن‬ ‫هللا‬ ‫بسم‬

2. Mesothelioma
Ahmed Abu-Naglah
Prof of chest diseases
Al Azhar university
2015

3. • Malignancies involving mesothelial cells that
normally line the body cavities, including the
pleura , peritoneum, pericardium, and testis,
are known as malignant mesothelioma.

4. Primary sites for malignant
mesothelioma
• pleura (87%)
• peritoneum (5.1%)
• pericardium (0.4%)
• the right side of the thorax (more so than the
left side, by a right-to-left ratio of 1.6:1)

5. Causes of mesothelioma

6. Asbestos
• Amphibole asbestos known as crocidolite and
amosite asbestos, is the principal carcinogen
implicated in the pathogenesis of malignant
pleural mesothelioma

7. Asbestos
• Wagner et al connected asbestos to
mesothelioma in a classic 1960 study of 33
patients with mesothelioma who were
exposed to asbestos in a mining area in South
Africa's North Western Cape Province.
• Of the 33 patients, 32 had been exposed to
crocidolite, the most carcinogenic type of
asbestos.

8. • Exposure to chrysotile asbestos is also
associated malignant mesothelioma, but at a
lower incidence than occurs with the other
types.
• (The rod-shaped amphiboles are more
carcinogenic than the chrysotile.)

9. industries associated with asbestos exposure
• Mining
• Ship building involving the use of asbestos
• Asbestos cement manufacture
• Ceramics
• Paper milling
• Auto parts (asbestos brake lining)
• Railroad repair
• Insulation

10. • Environmental exposure to asbestos in areas
polluted by the substance may also increase
the incidence of mesothelioma.

11. • Alcohol, dietary factors, and tobacco smoke
have no effect on the incidence of pleural
mesothelioma.

12. • The clinical latency period between asbestos
exposure and mesothelioma development is
35-40 years, and as a result, the number of
mesothelioma patients has continued to rise
despite decreased asbestos production

13. Other sources of mesothelioma
• Malignant mesothelioma has also been linked
to therapeutic radiation using thorium dioxide
and zeolite, a silicate in the soil.
• An etiologic role for simian virus 40 in
malignant mesothelioma has been suggested.

14. Genetics
• Loss of 1 copy of chromosome 22 is the single
most common karyotypic change in malignant
mesothelioma.

15. Clinical presentations

23. Ascites, omental caking, and mesenteric thickening.

24. Diagnosis
• Thoracoscopically guided biopsy should be
performed if mesothelioma is suggested
• The results are diagnostic in 98% of cases.

25. Malignant mesothelioma versus
adenocarcinoma
• Negative test results for periodic acid-Schiff
stain, mucicarmine stain, carcinoembryonic
antigen, and Leu M1
• positive test results for calretinin, vimentin,
and cytokeratin.

26. Electron microscopy
• Cells have long microvilli, in contrast to
adenocarcinomas, which have short microvilli

27. SMRP
• One of the new most intriguing markers is
serum mesothelin-related protein (SMRP),
measured in fluid or serum.
• The circulating SMRP level has been reported
to be elevated in 84% of patients with
malignant mesothelioma and in 2% of patients
with lung cancer.

28. Characteristics of new cell lines
• Four new mesothelioma cell lines have been
characterized based on ultrastructural and
immunophenotypic analysis.
• These cell lines express vimentin, cytokeratins
8 and 18, and mesothelial antigen recognized
by HBME-1 monoclonal antibody.

29. • All of the lines possess surface human
leukocyte antigen (HLA) class I and
intercellular adhesion molecule-1 (ICAM-1).

30. • Hollevoet et al found that megakaryocyte
potentiating factor (MPF) can be used as a
serum biomarker of malignant mesothelioma.
• MPF originates from the same precursor
protein as soluble mesothelin (SM)

31. Staging

32. Nodal metastasis
• The pattern of nodal metastasis is different
from that of lung cancer.
• The mechanism of spread of the disease to
the hilar nodes may be through lung invasion
and not due to spread directly from the
pleura.

33. Stage I
• Completely resected within the capsule of the
parietal pleura without adenopathy (ie,
ipsilateral pleura, lung, pericardium,
diaphragm, or chest wall disease limited to
previous biopsy sites)

34. Stage II
• All stage I characteristics, with positive
resection margins, intrapleural adenopathy, or
a combination

35. Stage III
• Local extension of disease into the chest wall
or mediastinum, into the heart, through the
diaphragm or peritoneum, or extrapleurally to
involve the lymph nodes

36. Stage IV
• Distant metastatic disease

37. Prognosis
• Without treatment, malignant mesothelioma
is fatal within 4-8 months. With trimodality
treatment, some patients have survived 16-19
months.

38. • A few have survived as long as 5 years, with
rates of 14% for all types and 46% for the
epithelial type. However, numbers are small.
• The tumor recurrence rate is 50% for patients
treated with surgery.

39. Prognostic factors
• Performance status of 2 or greater
• Nonepithelial histology
• Chest pain
• Age older than 75 years
• Male sex
• High platelet count
• Lactate dehydrogenase greater than 500 IU/L
• Low hemoglobin
• High white count
• Weight loss

40. Retrospective study of malignant pleural
mesothelioma in Al-Azhar University Hospitals
and El-Abassia Chest Hospital
(1996-2003)
Ahmed Ali Abu-Naglah, Sohair Soliman, Nagwa Fahmy and Hala Abdalla
Chest and General Medicine
Departments, Al-Azhar University

41. 345149196
11250622000
7141301999
6328351998
5417371997
4513321996
TotalFemaleMales

42. Male Female Total
2001 67 48 115
2002 71 56 127
2003 100 60 160
Total 238 171 402
Total from
1996-2003
428 319 747

43. 0
10
20
30
40
50
60
70
80
90
100
110
120
130
140
150
160
170
1996 1997 1998 1999 2000 2001 2002 2003

44. Age groups distribution among
patients
Males Females Total %
10 - < 20 1 2 3 0.40
20 - < 30 18 15 33 4.42
30 - < 40 67 48 115 15.39
40 - < 50 113 80 193 25.84
50 - < 60 117 91 208 27.84
60 - < 70 86 65 151 20.21
> 70 25 19 44 5.89
Total 428 319 747 100

45. The mean age of the patients
Males (N = 196) Females (N = 149)
Mean 49.86 48.94
SD  12.61  12.64
Range 18 – 80 16 – 80
T value 0.67
P value P > 0.05

46. Gender distribution among patients
Males Females
Number 428 319
% 57.3% 42.7%
P value < 0.01

47. Regional distribution among patients
Location Shobra El-Khama Other areas
Number of patients 448 299
% 59.9% 41.1%
P value < 0.01

48. Occupational distribution among
patients
Asbestos related House wife Others
Number of patients 295 246 203
% 39.13% 33.05% 27.82%
P value < 0.05

49. The main presenting symptoms
Dyspnea
Chest pain
Cough
Chest wall mass
Weight loss
60 %
45 %
16 %
2 %
2 %

50. Methods of diagnosis and yield of
them
Num of parients %
- Cytological exam
- Abram’s needle B.
- CT guided biopsy
- Thoracoscopic biopsy
- Open biopsy
112
173
74
209
179
14.9
23.4
9.9
27.9
23.9

51. The pathological types
Number of parienls %
Epithelial
Sarcomatous
Mixed
524
82
141
70.15
10.98
18.87

52. Site of the lesion at presentation
Number of patients %
RT. Sided
Left . sided
448
299
60 %
40 %

53. Durations of survive after presentation
(In 380 patients)
Duration
Range
Mean
2 months – 3 years
12 months

54. Treatment
Number of
patients
%
- Surgery
- Chemotherapy with or
without pleurodesis
- Radiotherapy
- Pleurodesis alone
- Combined
- Refuse treatment or undetected
57
239
89
97
82
203
4.9 %
31.7 %
11.8 %
12.6 %
10.8 %
27.2 %

55. Conclusion and Recommendations
• Malignant pleural mesothelioma is increasing
progressively in Egypt specially in industrial
areas.
• It affects younger age groups. About 45% of
patients below 50 years while in other
countries the median age of affection is 60
years

56. • The males to females ratio is 1.3 : 1 while in
united states mesothelioma is approximately
three fold more in men than in women. This
because most of the affected Egyptian women
are living at the industrial polluted areas.

57. • This disease is fatal within few months and
maximally few years even in younger patients.

58. • Preventive measures that attempt to eliminate or
at least reduce asbestos pollution are mandatory,
with the use of safer and alternative materials for
construction, insulation, and other consumer
and industrial applications and by dust control
and personal protection.
• The factories which use any type of asbestos
materials must be transferred to distinct areas
away from houses and populations.

59. Thank you