Mesothelioma Flashcards by Mollie O

What is the median age of presentation of mesothelioma?

60 years

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What does mesothelioma typically present after?

20-50 years after asbestos exposure

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What is the male to female ratio of mesothelioma?

5:1

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How is the risk of mesothelioma related to asbestos exposure?

It is estimated that the risk is linearly proportional to the intensity and duration of exposure

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What is the risk of the risk of mesothelioma being proportional to the intensity and duration of asbestos exposure?

The latency periods between first exposure to asbestos and diagnosis of mesothelioma may vary by occupation, with shorter intervals for insulators and dock workers, and longer intervals for shipyard and maritime workers, as well as domestic exposures

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What do a significant proportion of patients diagnosed with mesothelioma diagnosed between the ages of 20 and 40 report?

Household or neighbourhood exposure during childhood

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Do children who present with mesothelioma have a history of asbestos exposure?

They generally have no apparent asbestos exposure

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How long is it estimated that the incidence of mesothelioma will rise for?

Until 2020

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Why is the incidence of mesothelioma expected to fall after 2020?

Due to increasing awareness of the role of asbestos, and measures to reduce asbestos exposure

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How common is malignant mesothelioma?

Rare, <1% of cancers

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Is malignant mesothelioma aggressive?

Yes, highly aggressive

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Where does malignant mesothelioma arise from?

Primarily from the surface serosal cells of the pleural, peritoneal, and pericardial cavities

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What is the primary cause of malignant mesothelioma?

Exposure to asbestos fibres

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What % of patients with malignant mesothelioma have no history of exposure to asbestos fibres?

50%

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How does the risk of malignant mesothelioma vary depending on which kind of asbestos fibre the patient is exposed to?

It is highest with blue fibres (crocidolite), then brown (amosite), and least with white (chrysolite)

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What virus is a possible co-factor for malignant mesothelioma?

SV40

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Why is it thought that SV40 is a possible co-factor for malignant mesothelioma?

In 60-83% of human malignant mesotheliomas, the cells express SV40 DNA

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How does exposure to asbestos fibres cause malignant mesothelioma?

The exposure can produce reactive oxygen species when hydrogen peroxide and superoxide react to form hydroxyl radicals, which can induce DNA damage

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What % of patients with malignant mesothelioma present with intrathoracic symptoms?

90%

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What are the intrathoracic symptoms of malignant mesothelioma?

Cough
Dyspnoea
Non-pleuritic chest wall pain

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What symptoms can involvement of the mediastinal pleura in malignant mesothelioma cause?

Arrhythmias

- Dysphagia

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How common are symptoms due to the involvement of the mediastinal pleura in malignant mesothelioma?

Rare

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What systemic symptoms are common in mesothelioma?

Pyrexia of unknown origin
Sweats
Anorexia
Weight loss

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What are the less common symptoms of malignant mesothelioma?

Thrombocytosis
Disseminated intravascular coagulation
Thrombophlebitis
Haemolytic anaemia

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What examination features do most patients with malignant mesothelioma present with?

- Dullness at one lung base | - Unilateral pleural effusion on CXR

Can malignant mesothelioma present incidentally?

Yes, occasionally patients can present asymptomatically with effusion as an incidental finding

What % of patients with malignant mesothelioma have bilateral involvement at the time of diagnosis?

Less than 5%

What % of patients with malignant mesothelioma have right sided lesions?

60%

What is the predominant method by which malignant mesothelioma spreads?

Local invasion of the lung, extending into the fissures and interlobular septa, adjacent organs in the mediastinum and chest wall, and may track along chest drainage sites

What % of patients have thoracic lymph node invasion in malignant mesothelioma?

Up to 70%

Where do haematogenous metastases of malignant mesothelioma commonly spread to?

- Liver | - Lung

Where do haemotogenous metastases of malignant mesothelioma less commonly spread to?

- Kidney - Adrenals - Bone

What lymph nodes should be examined in malignant mesothelioma?

- Neck - Supraclavicular - Axillary

What should be looked for on hand examination in malignant mesothelioma?

- Clubbing | - Signs of smoking

What should be looked for on observation in malignant mesothelioma?

- Ascites | - Cachexia

What should be looked for on cardiovascular examination in malignant mesothelioma?

- Atrial fibrillation | - Pericardial effusion

What is atrial fibrillation a sign of in malignant mesothelioma?

Pericardial infiltration

What should be looked for on respiratory examination in malignant mesothelioma?

- Dyspnoea - Poor expansion - Dullness to percussion - Pleural effusion - Poor unilateral air entry

What should be looked for on abdominal examination in malignant mesothelioma?

- Abdominal distention | - Ascites

What should be looked for on neurological examination in malignant mesothelioma?

Spinal root involvement

What should be looked for on peripheral examination in malignant mesothelioma?

-Clubbing

How does malignant mesothelioma appear on CXR?

As a thickened, nodular, irregular pleural-based mass, which covers the pleural surface

What is visible on CXR in some malignant mesothelioma patients?

Pleural plaques

Why are pleural plaques visible on CXR in some patients with malignant mesothelioma?

Due to previous asbestos exposure

Describe the relationship of the malignant mesothelioma tumour and the lung?

It often encompasses and compresses the involved lung

What invasion might be seen in advanced cases of malignant mesothelioma?

- Chest wall - Diaphragmatic - Mediastinal invasion

What is often noted on the side of the affected lung in malignant mesothelioma?

Moderate to large pleural effusion

How can the extent of disease be assessed in malignant mesothelioma?

Using CT imaging

In what % of cases of malignant mesothelioma is pleural thickening >1cm seen?

92%

In what % of cases of malignant mesothelioma is pleural thickening which extends into the interlobular fissure seen?

85% cases

In what % of cases of malignant mesothelioma are pleural effusions seen?

74%

In what % of cases of malignant mesothelioma are pleural calcifications seen?

20-50%

Does the absence of pleural thickening exclude the diagnosis of malignant mesothelioma?

Can CT imaging differentiate between benign and malignant pleural thickening?

Yes

Can CT imaging reliably distinguish primary from metastatic malignancy in malignant mesothelioma?

What is stage I in malignant mesothelioma?

Tumour involving the right or left pleura, and may have spread to the lung, pericardium, or diaphragm on the same side. Lymph nodes are not involved

What is stage II in malignant mesothelioma?

Tumour has spread from the pleura on one side to nearby lymph nodes next to the lung on the same side. It may have spread into the lung, pericardium, or diaphragm on the same side

What is stage III in malignant mesothelioma?

Tumour is invading the chest wall, muscle, ribs, heart, oesophagus, or other organs in the chest on the same side, with or without spreading to the lymph nodes on the same side as the primary tumour

What is stage IV in malignant mesothelioma?

Tumour involving the lymph nodes in the chest on the side opposite the primary tumour, or extends to the pleura or lung on the opposite side, or directly extends into organs in the abdominal cavity or neck Any distant metastases are included in this stage

What might pulmonary function tests show in malignant mesothelioma?

Restrictive lung pattern

Why might pulmonary function tests show a restrictive pattern in malignant mesothelioma?

Resulting from encasement of the lung

Are obstructive spirometric changes related to mesothelioma or asbestosis?

What is the limitation of cytological assessment of the pleural fluid in malignant mesothelioma?

- 80% will have a false negative result | - Even with a positive result, may patients will still require a biopsy

What biopsy methods can be used to obtain a tissue sample in malignant mesothelioma?

- Percutaneous needle biopsy of the pleura or peritoneum - Open biopsy - Video-assisted thoracoscopic approach

What anaesthetic is required for a percutaneous needle biopsy of the pleura or peritoneum?

Local anaethestic

What is the limitation of percutaneous needle biopsy in malignant mesothelioma?

It is only diagnostic in 60% of patients with mesothelioma

What is the advantage of open biopsy in malignant mesothelioma?

- More reliable | - Provides larger tissue specimen for assessment

What can be performed at the same time as a video assisted thoracoscopic biopsy?

Talc pleurodesis with pleural strippping

What is the advantage of performing talc pleurodesis with pleural stripping in malignant mesothelioma?

Recurrent pleural effusions are common

What is the risk of biopsy in malignant mesothelioma?

Tumour seeding may occur along the needle tract of the biopsy

What % of patients develop tumour nodules along the needle tract of the biopsy site?

Approx 20%

What might help prevent nodule growth along the needle tract of the biopsy site in malignant mesothelioma?

Local radiotherapy to biopsy site

What is the limitation of treatment for malignant mesothelioma?

The majority of patients with mesothelioma present with incurable disease

What can be used to pallitate symptoms in malignant mesothelioma?

- Analgesics for chest pain - Antibiotics for infection - Cough suppressants

What is true of the approach to surgery and systemic treatments in malignant mesothelioma?

It is usually palliative

Why are surgery and systemic treatments usually palliative in malignant mesothelioma?

A cure is unlikely unless patients present with localised disease that can be resected

When is malignant mesothelioma operable?

When patients present with stage 1 disease with tumour confined to ipsilateral pleural space

What surgical techniques are used in the management of malignant mesothelioma?

- Decortication (pleurectomy) | - Extrapleural pneumonectomy

What is surgery followed by in malignant mesothelioma?

Adjuvant radiotherapy

What have trials shown about the benefit of surgery in malignant mesothelioma?

The extent of benefit of surgery has not been established through randomised clinical trails

What management can be used for more advanced malignant mesothelioma to control symptoms?

Radiotherapy

How can palliation be achieved in malignant mesothelioma?

Systemic chemotherapy using carboplatin (or cisplatin) and pemetrexed

How can radiotherapy be used to combat malignant mesothelioma?

Can be used to control metastasis at port sites following invasive procedures, and prevent growth at such sites

What can be used to control the symptoms of effusion in malignant melanoma?

- Drainage of pleural or pericardial effusion | - Pleurodesis

What is the 5 year survival for mesothelioma?

What is the average length of survival in malignant mesothelioma?

6-18 months

Don't let this Brainscape deck distract you from the fact that if you or a loved one has been diagnosed with mesothelioma, you may be entitled to... ?

Financial compensation In the UK, patients with asbestos-related mesothelioma are eligible for a lump sum payment in addition to their other benefit entitlements, and they should be directed to appropriate advice