IT IS NOT ALWAYS EMPYEMA

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IT IS NOT ALWAYS EMPYEMA

• Dr Ahmed AlGarzaie
• Pulmonary Club meeting
• 5/4/ 2005

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Case Presentation

• 60 yrs. Old man, farmer present to ER 12/3/05
• C/O Productive cough ,a mild SOB,
• PMS History
• Repair of soft cleft palate 7/04
• TURP 9/04
• Exam mild respirotry distress, afebrile VS
  stable , no palpable lymphadenopathy
• Chest no tracheal deviation ,decrease expansion
  in Rt side ,stony dullness in percussion in lower
  rt side ,decreased air entry at Rt lower zone

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Investigations

• SERUM
• CBC WBC 5.9, RBC 4.7 ,HGB 13.5
• U/E Na 142 ,K 3.8 ,BUN 3.8 ,creat 100
• LFT normal total protein 71
• LDH 136 glucose 5.2
• PLEURAL EFFUSION
• Glucose 0.1 total protein 74
• LDH 6967
• PH 8.0
• WBC 2350 , RBC 13600

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1 year ago
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The Histopathology

• Pleural effusion Cytology
• Malignant epithelial cells present
• Histopathology
• Malignant Epithelial neoplasm most likely
  MESOTHELIOMA

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• Types of Mesothelioma
• Epitheloid
• Sarcomatoid
• Mixed
• Immunohistochemistry
• CK
• Vimentin
• EMA
• S-100
• Berep4
• CEA -

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Diffuse Malignant Mesothelioma
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Introduction

• Uncommon and lethal cancer
• No standard treatment
• Klemperer and Rabin (1937) classified
  mesotheliomas as either localized or diffuse
• Asbestos exposure was the major risk factor for
  MM.

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• The peak age for the development of MM is the
  sixth decade of life
• Men women 51

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Pathology

• Mesotheliomas arise from multipotential
  mesothelial or subserosal cells that can develop
  into either an epithelial or a sarcomatoid
  neoplasm
• In review of 819 cases, Hillerdal (1983) reported
  that 50 were of epithelial type, 34 were of
  mixed type, and 16
  were of sarcomatoid type
• The histologic appearance is easily confused with
  that of other neoplasms

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Clinical Presentation

• Insidious and nonspecific
• Early stages dyspnea is related to the to the
  presence of an effusion.
• As the tumor grows, patients develop ill defined,
  mild but continuous chest discomfort
• With tumor growth, the pleural surfaces fuse, and
  the effusion resolves
• Severe chest pain is related to tumor
  infiltration of the chest wall and intercostal
  nerves
• In the final stages of disease dyspnea and chest
  pain become severe and unremitting
• Pericardial effusion , myocardial metastases
• ascites

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The Radiologic Presentation

• Is variable and is related to the stage of the
  tumor at diagnosis
• In early-stage, a large pleural effusion is often
  the only sign of disease
• Subtle pleural thickening or small, discrete,
  pleural-based masses may be seen on ( CT )
• Subsequently larger pleural pleural-based mases
• Mediastinal adenopathy
• (PET) scan

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Staging Proposed by Butchart and Colleagues (1976)

• Stage 1 Tumor confined within the capsule of the
  parietal pleura ( involving only ipsilateral
  pleura, lung, pericardium, and diaphragm)
• Stage 2 tumor invading chest wall or involving
  mediastinal structures (e.g esophagus, heart,
  opposite pleura)
  Lymph node
  involvement in the chest
• Stage 3 Tumor penetrating diaphragm to involve
  peritonium, involvement of opposite pleura
  lymph node involvement outside the chest
• Stage 4 Distant blood-borne metastases
• (TNM)- based system by Chahinian (1983)

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Treatment

• Surgery
• Radiation therapy
• Chemotherapy
• Immunotherapy
• Supportive care
• Combination of these modalities

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Surgery

• Extrapleural pneumonectomy
  ( pleuropneumonectomy )
• Pleurectomy-decortication
• Palliative limited pleurectomy

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Chemotherapy

• Response rate in the 20 range
• Active agent include doxorubicin, detorubicin ,
  ifosfamide, cisplatine, 5-fluorouracil and
  methotrexate
• A new agent Pemetrexed

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Conclusion

• Diffuse malignant pleural mesothelioma is
  uncommon and lethal cancer
• It is disappointing for the treatment of patients
  with MPM
• Further understanding of this disease could also
  lead to newer and more targeted treatments

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