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Martella S, Aiello MM, Bertaglia V, Cau R, Denaro N, Cadoni A, Novello S, Scartozzi M, Novello G, Soto Parra HJ, Saba L, Solinas C, Porcu M. Malignant Pleural Mesothelioma: Staging and Radiological Response Criteria in Patients Treated with Immune Checkpoint Inhibitors. Target Oncol 2024; 19:13-28. [PMID: 38063957 DOI: 10.1007/s11523-023-01017-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2023] [Indexed: 02/01/2024]
Abstract
Malignant pleural mesothelioma (MPM) is a rare and challenging cancer associated with asbestos fiber exposure, which offers limited treatment options. Historically, platinum-based chemotherapy has been the primary approach, but recent developments have introduced immunotherapy as a promising alternative for the treatment of this disease. Nevertheless, the unique growth patterns and occasionally ambiguous progressive characteristics of MPM make the interpretation of radiological assessments complex. Immunotherapy further complicates matters by introducing unconventional treatment response patterns such as hyperprogression and pseudoprogression. Consequently, there is a growing imperative to integrate the standard RECIST criteria with the mesothelioma-specific mRECIST criteria (version 1.1), as outlined in iRECIST. This comprehensive review is driven by the intent to provide a valuable resource for radiologists and clinicians engaged in the diagnosis, treatment, and monitoring of MPM in the era of immunotherapy. Specifically, the current imaging methods employed for staging and follow-up will be exposed and discussed, with a focus on the technical specificities and the mRECIST 1.1 methodology. Furthermore, we will provide a discussion about major clinical trials related to the use of immunotherapy in MPM patients. Finally, the latest advancements in radiomics, the applications of artificial intelligence in MPM, and their potential impact on clinical practice for prognosis and therapy, are discussed.
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Affiliation(s)
- Serafina Martella
- Department of Medical Oncology, University Hospital Policlinico San Marco, Catania, Italy
| | - Marco Maria Aiello
- Department of Medical Oncology, University Hospital Policlinico San Marco, Catania, Italy
| | - Valentina Bertaglia
- Department of Oncology, San Luigi Gonzaga Hospital, University of Turin, Turin, Italy
| | - Riccardo Cau
- Department of Radiology, AOU Cagliari, S.S: 554, km 4,500, CAP: 09042, Monserrato (CA), Italy
| | - Nerina Denaro
- Department of Medical Oncology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Andrea Cadoni
- Department of Medical Oncology, AOU Cagliari, Monserrato (CA), Italy
| | - Silvia Novello
- Department of Oncology, San Luigi Gonzaga Hospital, University of Turin, Turin, Italy
| | - Mario Scartozzi
- Department of Medical Oncology, AOU Cagliari, Monserrato (CA), Italy
| | - Giuseppe Novello
- Department of Medical Oncology, University Hospital Policlinico San Marco, Catania, Italy
| | - Hector Josè Soto Parra
- Department of Medical Oncology, University Hospital Policlinico San Marco, Catania, Italy
| | - Luca Saba
- Department of Radiology, AOU Cagliari, S.S: 554, km 4,500, CAP: 09042, Monserrato (CA), Italy
| | - Cinzia Solinas
- Department of Oncology, San Luigi Gonzaga Hospital, University of Turin, Turin, Italy
| | - Michele Porcu
- Department of Radiology, AOU Cagliari, S.S: 554, km 4,500, CAP: 09042, Monserrato (CA), Italy.
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Broncano J, Steinbrecher K, Marquis KM, Raptis CA, Royuela Del Val J, Vollmer I, Bhalla S, Luna A. Diffusion-weighted Imaging of the Chest: A Primer for Radiologists. Radiographics 2023; 43:e220138. [PMID: 37347699 DOI: 10.1148/rg.220138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/24/2023]
Abstract
Diffusion-weighted imaging (DWI) is a fundamental sequence not only in neuroimaging but also in oncologic imaging and has emerging applications for MRI evaluation of the chest. DWI can be used in clinical practice to enhance lesion conspicuity, tissue characterization, and treatment response. While the spatial resolution of DWI is in the order of millimeters, changes in diffusion can be measured on the micrometer scale. As such, DWI sequences can provide important functional information to MRI evaluation of the chest but require careful optimization of acquisition parameters, notably selection of b values, application of parallel imaging, fat saturation, and motion correction techniques. Along with assessment of morphologic and other functional features, evaluation of DWI signal attenuation and apparent diffusion coefficient maps can aid in tissue characterization. DWI is a noninvasive noncontrast acquisition with an inherent quantitative nature and excellent reproducibility. The outstanding contrast-to-noise ratio provided by DWI can be used to improve detection of pulmonary, mediastinal, and pleural lesions, to identify the benign nature of complex cysts, to characterize the solid portions of cystic lesions, and to classify chest lesions as benign or malignant. DWI has several advantages over fluorine 18 (18F)-fluorodeoxyglucose PET/CT in the assessment, TNM staging, and treatment monitoring of lung cancer and other thoracic neoplasms with conventional or more recently developed therapies. © RSNA, 2023 Quiz questions for this article are available in the supplemental material. Supplemental material and the slide presentation from the RSNA Annual Meeting are available for this article.
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Affiliation(s)
- Jordi Broncano
- From the Cardiothoracic Imaging Unit (J.B.) and Department of Radiology (J.B., J.R.d.V.), Hospital San Juan de Dios, HT-RESSALTA, HT Médica, Avenida el Brillante No. 36, 14012 Córdoba, Spain; Cardiothoracic Imaging Section, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (K.S., K.M.M., C.A.R., S.B.); Cardiothoracic Imaging Section, Department of Radiology, Hospital Clínic de Barcelona, Barcelona, Spain (I.V.); and MRI Section, Department of Radiology, Clínica Las Nieves, HT-SERCOSA, HT Médica, Jaén, Spain (A.L.)
| | - Kacie Steinbrecher
- From the Cardiothoracic Imaging Unit (J.B.) and Department of Radiology (J.B., J.R.d.V.), Hospital San Juan de Dios, HT-RESSALTA, HT Médica, Avenida el Brillante No. 36, 14012 Córdoba, Spain; Cardiothoracic Imaging Section, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (K.S., K.M.M., C.A.R., S.B.); Cardiothoracic Imaging Section, Department of Radiology, Hospital Clínic de Barcelona, Barcelona, Spain (I.V.); and MRI Section, Department of Radiology, Clínica Las Nieves, HT-SERCOSA, HT Médica, Jaén, Spain (A.L.)
| | - Kaitlin M Marquis
- From the Cardiothoracic Imaging Unit (J.B.) and Department of Radiology (J.B., J.R.d.V.), Hospital San Juan de Dios, HT-RESSALTA, HT Médica, Avenida el Brillante No. 36, 14012 Córdoba, Spain; Cardiothoracic Imaging Section, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (K.S., K.M.M., C.A.R., S.B.); Cardiothoracic Imaging Section, Department of Radiology, Hospital Clínic de Barcelona, Barcelona, Spain (I.V.); and MRI Section, Department of Radiology, Clínica Las Nieves, HT-SERCOSA, HT Médica, Jaén, Spain (A.L.)
| | - Constantin A Raptis
- From the Cardiothoracic Imaging Unit (J.B.) and Department of Radiology (J.B., J.R.d.V.), Hospital San Juan de Dios, HT-RESSALTA, HT Médica, Avenida el Brillante No. 36, 14012 Córdoba, Spain; Cardiothoracic Imaging Section, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (K.S., K.M.M., C.A.R., S.B.); Cardiothoracic Imaging Section, Department of Radiology, Hospital Clínic de Barcelona, Barcelona, Spain (I.V.); and MRI Section, Department of Radiology, Clínica Las Nieves, HT-SERCOSA, HT Médica, Jaén, Spain (A.L.)
| | - Javier Royuela Del Val
- From the Cardiothoracic Imaging Unit (J.B.) and Department of Radiology (J.B., J.R.d.V.), Hospital San Juan de Dios, HT-RESSALTA, HT Médica, Avenida el Brillante No. 36, 14012 Córdoba, Spain; Cardiothoracic Imaging Section, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (K.S., K.M.M., C.A.R., S.B.); Cardiothoracic Imaging Section, Department of Radiology, Hospital Clínic de Barcelona, Barcelona, Spain (I.V.); and MRI Section, Department of Radiology, Clínica Las Nieves, HT-SERCOSA, HT Médica, Jaén, Spain (A.L.)
| | - Ivan Vollmer
- From the Cardiothoracic Imaging Unit (J.B.) and Department of Radiology (J.B., J.R.d.V.), Hospital San Juan de Dios, HT-RESSALTA, HT Médica, Avenida el Brillante No. 36, 14012 Córdoba, Spain; Cardiothoracic Imaging Section, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (K.S., K.M.M., C.A.R., S.B.); Cardiothoracic Imaging Section, Department of Radiology, Hospital Clínic de Barcelona, Barcelona, Spain (I.V.); and MRI Section, Department of Radiology, Clínica Las Nieves, HT-SERCOSA, HT Médica, Jaén, Spain (A.L.)
| | - Sanjeev Bhalla
- From the Cardiothoracic Imaging Unit (J.B.) and Department of Radiology (J.B., J.R.d.V.), Hospital San Juan de Dios, HT-RESSALTA, HT Médica, Avenida el Brillante No. 36, 14012 Córdoba, Spain; Cardiothoracic Imaging Section, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (K.S., K.M.M., C.A.R., S.B.); Cardiothoracic Imaging Section, Department of Radiology, Hospital Clínic de Barcelona, Barcelona, Spain (I.V.); and MRI Section, Department of Radiology, Clínica Las Nieves, HT-SERCOSA, HT Médica, Jaén, Spain (A.L.)
| | - Antonio Luna
- From the Cardiothoracic Imaging Unit (J.B.) and Department of Radiology (J.B., J.R.d.V.), Hospital San Juan de Dios, HT-RESSALTA, HT Médica, Avenida el Brillante No. 36, 14012 Córdoba, Spain; Cardiothoracic Imaging Section, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (K.S., K.M.M., C.A.R., S.B.); Cardiothoracic Imaging Section, Department of Radiology, Hospital Clínic de Barcelona, Barcelona, Spain (I.V.); and MRI Section, Department of Radiology, Clínica Las Nieves, HT-SERCOSA, HT Médica, Jaén, Spain (A.L.)
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Strange CD, Marom EM, Ahuja J, Shroff GS, Gladish GW, Carter BW, Truong MT. Imaging of Malignant Pleural, Pericardial, and Peritoneal Mesothelioma. Adv Anat Pathol 2023; 30:280-291. [PMID: 36395181 DOI: 10.1097/pap.0000000000000386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Malignant mesothelioma is a rare tumor arising from the mesothelial cells that line the pleura, pericardium, peritoneum, and tunica vaginalis. Imaging plays a primary role in the diagnosis, staging, and management of malignant mesothelioma. Multimodality imaging, including radiography, computed tomography (CT), magnetic resonance imaging (MRI), and F-18 fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT), is used in a variety of scenarios, including diagnosis, guidance for tissue sampling, staging, and reassessment of disease after therapy. CT is the primary imaging modality used in staging. MRI has superior contrast resolution compared with CT and can add value in terms of determining surgical resectability in equivocal cases. MRI can further assess the degree of local invasion, particularly into the mediastinum, chest wall, and diaphragm, for malignant pleural and pericardial mesotheliomas. FDG PET/CT plays a role in the diagnosis and staging of malignant pleural mesothelioma (MPM) and has been shown to be more accurate than CT, MRI, and PET alone in the staging of malignant pleural mesothelioma. PET/CT can also be used to target lesions for biopsy and to assess prognosis, treatment response, and tumor recurrence.
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Affiliation(s)
- Chad D Strange
- Department of Thoracic Imaging, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Edith M Marom
- Department of Diagnostic Radiology, Chaim Sheba Medical Center, Tel Aviv University, Ramat Gan, Israel
| | - Jitesh Ahuja
- Department of Thoracic Imaging, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Girish S Shroff
- Department of Thoracic Imaging, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Gregory W Gladish
- Department of Thoracic Imaging, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Brett W Carter
- Department of Thoracic Imaging, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Mylene T Truong
- Department of Thoracic Imaging, University of Texas MD Anderson Cancer Center, Houston, TX
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Kidd AC, Anderson O, Cowell GW, Weir AJ, Voisey JP, Evison M, Tsim S, Goatman KA, Blyth KG. Fully automated volumetric measurement of malignant pleural mesothelioma by deep learning AI: validation and comparison with modified RECIST response criteria. Thorax 2022; 77:1251-1259. [PMID: 35110367 PMCID: PMC9685726 DOI: 10.1136/thoraxjnl-2021-217808] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 12/20/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND In malignant pleural mesothelioma (MPM), complex tumour morphology results in inconsistent radiological response assessment. Promising volumetric methods require automation to be practical. We developed a fully automated Convolutional Neural Network (CNN) for this purpose, performed blinded validation and compared CNN and human response classification and survival prediction in patients treated with chemotherapy. METHODS In a multicentre retrospective cohort study; 183 CT datasets were split into training and internal validation (123 datasets (80 fully annotated); 108 patients; 1 centre) and external validation (60 datasets (all fully annotated); 30 patients; 3 centres). Detailed manual annotations were used to train the CNN, which used two-dimensional U-Net architecture. CNN performance was evaluated using correlation, Bland-Altman and Dice agreement. Volumetric response/progression were defined as ≤30%/≥20% change and compared with modified Response Evaluation Criteria In Solid Tumours (mRECIST) by Cohen's kappa. Survival was assessed using Kaplan-Meier methodology. RESULTS Human and artificial intelligence (AI) volumes were strongly correlated (validation set r=0.851, p<0.0001). Agreement was strong (validation set mean bias +31 cm3 (p=0.182), 95% limits 345 to +407 cm3). Infrequent AI segmentation errors (4/60 validation cases) were associated with fissural tumour, contralateral pleural thickening and adjacent atelectasis. Human and AI volumetric responses agreed in 20/30 (67%) validation cases κ=0.439 (0.178 to 0.700). AI and mRECIST agreed in 16/30 (55%) validation cases κ=0.284 (0.026 to 0.543). Higher baseline tumour volume was associated with shorter survival. CONCLUSION We have developed and validated the first fully automated CNN for volumetric MPM segmentation. CNN performance may be further improved by enriching future training sets with morphologically challenging features. Volumetric response thresholds require further calibration in future studies.
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Affiliation(s)
- Andrew C Kidd
- Glasgow Pleural Disease Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Owen Anderson
- School of Computing Science, University of Glasgow, Glasgow, UK
- Canon Medical Research Europe Ltd, Edinburgh, UK
| | - Gordon W Cowell
- Department of Imaging, Queen Elizabeth University Hospital, Glasgow, UK
| | | | | | - Matthew Evison
- Department of Respiratory Medicine, University Hospital of South Manchester, Manchester, UK
| | - Selina Tsim
- Glasgow Pleural Disease Unit, Queen Elizabeth University Hospital, Glasgow, UK
- Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
| | | | - Kevin G Blyth
- Glasgow Pleural Disease Unit, Queen Elizabeth University Hospital, Glasgow, UK
- Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
- Beatson Institute for Cancer Research, Glasgow, UK
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Lopci E, Castello A, Mansi L. FDG PET/CT for Staging and Restaging Malignant Mesothelioma. Semin Nucl Med 2022; 52:806-815. [PMID: 35965111 DOI: 10.1053/j.semnuclmed.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 07/19/2022] [Accepted: 07/25/2022] [Indexed: 11/11/2022]
Abstract
Malignant mesothelioma is an aggressive tumor originating from the mesothelial cells and presenting in general with a very poor prognosis. The pleural localization represents the prevailing disease site, while peritoneal involvement is commonly rare. The WHO classifies mesotheliomas into epithelioid, biphasic, and sarcomatoid histotypes, having diverse outcome with the sarcomatoid or biphasic forms showing the poorest prognosis. Given the peculiar rind-like pattern of growth, mesothelioma assessment is rather challenging for medical imagers. Conventional imaging is principally based on contrast-enhanced CT, while the role of functional and metabolic imaging is regarded as complementary. By focusing essentially on the staging and restaging role of [18F]FDG PET/CT in malignant mesotheliomas, the present review will summarize the available data present in literature and provide some hints on alternative imaging and future perspectives. Given the prevailing incidence of pleural disease, the majority of the information will be addressed on malignant pleural mesothelioma, although a summary of principal characteristics and imaging findings in patients with peritoneal mesothelioma will be also provided.
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Affiliation(s)
- Egesta Lopci
- Nuclear Medicine Unit, IRCCS - Humanitas Research Hospital, Milan, Italy.
| | - Angelo Castello
- Nuclear Medicine Unit, Fondazione IRCCS Ca' Granda, Milan, Italy
| | - Luigi Mansi
- Interuniversity Research Center for the Sustainable Development (CIRPS), Rome, Italy
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Dejanovic D, Specht L, Czyzewska D, Kiil Berthelsen A, Loft A. Response Evaluation Following Radiation Therapy With 18F-FDG PET/CT: Common Variants of Radiation-Induced Changes and Potential Pitfalls. Semin Nucl Med 2022; 52:681-706. [PMID: 35835618 DOI: 10.1053/j.semnuclmed.2022.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 06/02/2022] [Accepted: 06/06/2022] [Indexed: 11/11/2022]
Abstract
Radiation therapy (RT) is one of the cornerstones in cancer treatment and approximately half of all patients will receive some form of RT during the course of their cancer management. Response evaluation after RT and follow-up imaging with 18F-Fluorodeoxyglucose (18F-FDG) positron emission tomography/computed tomography (PET/CT) can be complicated by RT-induced acute, chronic or consequential effects. There is a general consensus that 18F-FDG PET/CT for response evaluation should be delayed for 12 weeks after completing RT to minimize the risk of false-positive findings. Radiation-induced late side effects in normal tissue can take years to develop and eventually cause symptoms that on imaging can potentially mimic recurrent disease. Imaging findings in radiation induced injuries depend on the normal tissue included in the irradiated volume and the radiation therapy regime including the total dose delivered, dose per fraction and treatment schedule. The intent for radiation therapy should be taken in consideration when evaluating the response on imaging, that is palliative vs curative or neoadjuvant vs adjuvant RT. Imaging findings can further be distorted by altered anatomy and sequelae following surgery within the radiation field. An awareness of common PET/CT-induced changes/injuries is essential when interpreting 18F-FDG PET/CT as well as obtaining a complete medical history, as patients are occasionally scanned for an unrelated cause to previously RT treated malignancy. In addition, secondary malignancies due to carcinogenic effects of radiation exposure in long-term cancer survivors should not be overlooked. 18F-FDG PET/CT can be very useful in response evaluation and follow-up in patients treated with RT, however, variants and pitfalls are common and it is important to remember that radiation-induced injury is often a diagnosis of exclusion.
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Affiliation(s)
- Danijela Dejanovic
- Department of Clinical Physiology, Nuclear Medicine and PET, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
| | - Lena Specht
- Department of Oncology, Rigshospitalet, Copenhagen University, Copenhagen, Denmark
| | - Dorota Czyzewska
- Department of Clinical Physiology, Nuclear Medicine and PET, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Anne Kiil Berthelsen
- Department of Oncology, Rigshospitalet, Copenhagen University, Copenhagen, Denmark
| | - Annika Loft
- Department of Clinical Physiology, Nuclear Medicine and PET, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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Strange CD, Shroff GS, Ahuja J, Vlahos I, Benveniste MFK, Truong MT. Imaging of Malignant Pleural Mesothelioma: Pearls and Pitfalls. Semin Ultrasound CT MR 2021; 42:542-551. [PMID: 34895610 DOI: 10.1053/j.sult.2021.04.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Malignant pleural mesothelioma is a rare tumor arising from the pleural mesothelial cells. Imaging plays a crucial role in the diagnosis, staging, and management of patients with mesothelioma. Accurate staging to stratify patients into homogeneous groups is required to evaluate the effectiveness of multimodality therapeutic regimens. CT and PET/CT are recommended for the initial staging of MPM. MRI adds value to further assess invasion of the tumor into the diaphragm, chest wall, and mediastinum. This review will discuss pearls and pitfalls in the imaging of mesothelioma with emphasis on the roles of CT, MRI, and PET/CT.
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Affiliation(s)
- Chad D Strange
- Department of Thoracic Imaging, MD Anderson Cancer Center, Houston, TX.
| | - Girish S Shroff
- Department of Thoracic Imaging, MD Anderson Cancer Center, Houston, TX
| | - Jitesh Ahuja
- Department of Thoracic Imaging, MD Anderson Cancer Center, Houston, TX
| | - Ioannis Vlahos
- Department of Thoracic Imaging, MD Anderson Cancer Center, Houston, TX
| | | | - Mylene T Truong
- Department of Thoracic Imaging, MD Anderson Cancer Center, Houston, TX
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Ricciardi S, Carleo F, Jaus MO, Di Martino M, Carbone L, Ricci A, Cardillo G. Malignant Pleural Mesothelioma Nodal Status: Where Are We at? J Clin Med 2021; 10:jcm10215177. [PMID: 34768701 PMCID: PMC8584902 DOI: 10.3390/jcm10215177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 10/27/2021] [Accepted: 11/03/2021] [Indexed: 11/16/2022] Open
Abstract
Due to the lack of both prospective trial and high-volume retrospective studies, the management of clinical N+ malignant pleural mesothelioma (MPM) patients remains highly debated. Node positive patients show poor survival compared with node-negative ones; thus, lymph node staging appears crucial in determining treatment strategy. Notwithstanding the improvement in pre-treatment staging and the update on lymph node classification in the 8th edition of TNM, several open controversies remain on N parameter. How should we stage suspected N+ patients? How should we treat node positive patients? Which is the definition of a “resectable patient”? Is the site or the number the main prognostic factor for node positive patients? The aim of our narrative review is to analyse the existing relevant literature on lymph node status in MPM.
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Affiliation(s)
- Sara Ricciardi
- Unity of Thoracic Surgery, Hospital of Bologna, IRCCS University, 40138 Bologna, Italy
- Alma Mater, Studiorum University of Bologna, 40138 Bologna, Italy
- Correspondence:
| | - Francesco Carleo
- Unity of Thoracic Surgery, San Camillo Forlanini Hospital, 00152 Rome, Italy; (F.C.); (M.O.J.); (M.D.M.); (L.C.); (G.C.)
| | - Massimo O. Jaus
- Unity of Thoracic Surgery, San Camillo Forlanini Hospital, 00152 Rome, Italy; (F.C.); (M.O.J.); (M.D.M.); (L.C.); (G.C.)
| | - Marco Di Martino
- Unity of Thoracic Surgery, San Camillo Forlanini Hospital, 00152 Rome, Italy; (F.C.); (M.O.J.); (M.D.M.); (L.C.); (G.C.)
| | - Luigi Carbone
- Unity of Thoracic Surgery, San Camillo Forlanini Hospital, 00152 Rome, Italy; (F.C.); (M.O.J.); (M.D.M.); (L.C.); (G.C.)
| | - Alberto Ricci
- Respiratory Unit, Sant’Andrea Hospital, 00189 Rome, Italy;
- Medicina Clinica e Molecolare, University of Rome La Sapienza, 00185 Rome, Italy
| | - Giuseppe Cardillo
- Unity of Thoracic Surgery, San Camillo Forlanini Hospital, 00152 Rome, Italy; (F.C.); (M.O.J.); (M.D.M.); (L.C.); (G.C.)
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Romei C, Fanni SC, Volpi F, Milazzo A, D’Amore CA, Colligiani L, Neri E, De Liperi A, Stella GM, Bortolotto C. New Updates of the Imaging Role in Diagnosis, Staging, and Response Treatment of Malignant Pleural Mesothelioma. Cancers (Basel) 2021; 13:cancers13174377. [PMID: 34503186 PMCID: PMC8430786 DOI: 10.3390/cancers13174377] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 08/24/2021] [Accepted: 08/27/2021] [Indexed: 11/16/2022] Open
Abstract
Malignant pleural mesothelioma is a rare neoplasm with poor prognosis. CT is the first imaging technique used for diagnosis, staging, and assessment of therapy response. Although, CT has intrinsic limitations due to low soft tissue contrast and the current staging system as well as criteria for evaluating response, it does not consider the complex growth pattern of this tumor. Computer-based methods have proven their potentiality in diagnosis, staging, prognosis, and assessment of therapy response; moreover, computer-based methods can make feasible tasks like segmentation that would otherwise be impracticable. MRI, thanks to its high soft tissue contrast evaluation of contrast enhancement and through diffusion-weighted-images, could replace CT in many clinical settings.
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Affiliation(s)
- Chiara Romei
- 2nd Radiology Unit, Radiology Department, Pisa University Hospital, 56124 Pisa, Italy;
- Correspondence: (C.R.); (S.C.F.)
| | - Salvatore Claudio Fanni
- Department of Translational Research, Academic Radiology, University of Pisa, 56124 Pisa, Italy; (F.V.); (A.M.); (C.A.D.); (L.C.); (E.N.)
- Correspondence: (C.R.); (S.C.F.)
| | - Federica Volpi
- Department of Translational Research, Academic Radiology, University of Pisa, 56124 Pisa, Italy; (F.V.); (A.M.); (C.A.D.); (L.C.); (E.N.)
| | - Alessio Milazzo
- Department of Translational Research, Academic Radiology, University of Pisa, 56124 Pisa, Italy; (F.V.); (A.M.); (C.A.D.); (L.C.); (E.N.)
| | - Caterina Aida D’Amore
- Department of Translational Research, Academic Radiology, University of Pisa, 56124 Pisa, Italy; (F.V.); (A.M.); (C.A.D.); (L.C.); (E.N.)
| | - Leonardo Colligiani
- Department of Translational Research, Academic Radiology, University of Pisa, 56124 Pisa, Italy; (F.V.); (A.M.); (C.A.D.); (L.C.); (E.N.)
| | - Emanuele Neri
- Department of Translational Research, Academic Radiology, University of Pisa, 56124 Pisa, Italy; (F.V.); (A.M.); (C.A.D.); (L.C.); (E.N.)
| | - Annalisa De Liperi
- 2nd Radiology Unit, Radiology Department, Pisa University Hospital, 56124 Pisa, Italy;
| | - Giulia Maria Stella
- Unit of Respiratory Diseases, Department of Medical Sciences and Infective Diseases, IRCCS Policlinico San Matteo Foundation, University of Pavia Medical School, 27100 Pavia, Italy;
| | - Chandra Bortolotto
- Unit of Radiology, Department of Intensive Medicine, IRCCS Policlinico San Matteo Foundation, University of Pavia Medical School, 27100 Pavia, Italy;
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Lauk O, Patella M, Neuer T, Battilana B, Frauenfelder T, Nguyen-Kim TDL, Weder W, Caviezel C, Hillinger S, Inci I, Opitz I. Implementing CT tumor volume and CT pleural thickness into future staging systems for malignant pleural mesothelioma. Cancer Imaging 2021; 21:48. [PMID: 34344472 PMCID: PMC8330125 DOI: 10.1186/s40644-021-00415-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 06/09/2021] [Indexed: 11/23/2022] Open
Abstract
Objectives Tumor thickness and tumor volume measured by computed tomography (CT) were suggested as valuable prognosticator for patients’ survival diagnosed with malignant pleural mesothelioma (MPM). The purpose was to assess the accuracy of CT scan based preoperatively measured tumor volume and thickness compared to actual tumor weight of resected MPM specimen and pathologically assessed tumor thickness, as well as an analysis of their impact on overall survival (OS). Methods Between 09/2013–08/2018, 74 patients were treated with induction chemotherapy followed by (extended) pleurectomy/decortication ((E)PD). In 53 patients, correlations were made between CT-measured volume and -tumor thickness (cTV and cTT) and actual tumor weight (pTW) based on the available values. Further cTV and pT/IMIG stage were correlated using Pearson correlation. Overall survival (OS) was calculated with Kaplan Meier analysis and tested with log rank test. For correlation with OS Kaplan-Meier curves were made and log rank test was performed for all measurements dichotomized at the median. Results Median pathological tumor volume (pTV) and pTW were 530 ml [130 ml – 1000 ml] and 485 mg [95 g – 982 g] respectively. Median (IQR) cTV was 77.2 ml (35.0–238.0), median cTT was 9.0 mm (6.2–13.7). Significant association was found between cTV and pTV (R = 0.47, p < 0.001) and between cTT and IMIG stage (p = 0,001) at univariate analysis. Multivariate regression analysis revealed, that only cTV correlates with pTV. Median follow-up time was 36.3 months with 30 patients dead at the time of the analysis. Median OS was 23.7 months. 1-year and 3-year survival were 90 and 26% respectively and only the cTV remained statistically associated with OS. Conclusion Preoperatively assessed CT tumor volume and actual tumor volume showed a significant correlation. CT tumor volume may predict pathological tumor volume as a reflection of tumor burden, which supports the integration of CT tumor volume into future staging systems.
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Affiliation(s)
- Olivia Lauk
- Department of Thoracic Surgery, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Miriam Patella
- Department of Thoracic Surgery, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Thomas Neuer
- Department of Thoracic Surgery, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Bianca Battilana
- Department of Thoracic Surgery, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Thomas Frauenfelder
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Thi Dan Linh Nguyen-Kim
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Walter Weder
- Department of Thoracic Surgery, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Claudio Caviezel
- Department of Thoracic Surgery, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Sven Hillinger
- Department of Thoracic Surgery, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Ilhan Inci
- Department of Thoracic Surgery, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Isabelle Opitz
- Department of Thoracic Surgery, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.
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11
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Song J, Nam BD, Yoon SH, Yoo JY, Jeong YJ, Yeo CD, Lim SY, Lee SY, Kim HK, Kim BH, Jin KN, Yong HS. [Korean Clinical Imaging Guidelines for the Appropriate Use of Chest MRI]. TAEHAN YONGSANG UIHAKHOE CHI 2021; 82:562-574. [PMID: 36238776 PMCID: PMC9432450 DOI: 10.3348/jksr.2020.0185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 01/15/2021] [Accepted: 02/01/2021] [Indexed: 11/15/2022]
Abstract
MRI has the advantages of having excellent soft-tissue contrast and providing functional information without any harmful ionizing radiation. Although previous technical limitations restricted the use of chest MRI, recent technological advances and expansion of insurance coverage are increasing the demand for chest MRI. Recognizing the need for guidelines on appropriate use of chest MRI in Korean clinical settings, the Korean Society of Radiology has composed a development committee, working committee, and advisory committee to develop Korean chest MRI justification guidelines. Five key questions were selected and recommendations have been made with the evidence-based clinical imaging guideline adaptation methodology. Recommendations are as follows. Chest MRI can be considered in the following circumstances: for patients with incidentally found anterior mediastinal masses to exclude non-neoplastic conditions, for pneumoconiosis patients with lung masses to differentiate progressive massive fibrosis from lung cancer, and when invasion of the chest wall, vertebrae, diaphragm, or major vessels by malignant pleural mesothelioma or non-small cell lung cancer is suspected. Chest MRI without contrast enhancement or with minimal dose low-risk contrast media can be considered for pregnant women with suspected pulmonary embolism. Lastly, chest MRI is recommended for patients with pancoast tumors planned for radical surgery.
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12
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Schumann SO, Kocher G, Minervini F. Epidemiology, diagnosis and treatment of the malignant pleural mesothelioma, a narrative review of literature. J Thorac Dis 2021; 13:2510-2523. [PMID: 34012597 PMCID: PMC8107529 DOI: 10.21037/jtd-20-2761] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The malignant pleural mesothelioma is a very aggressive tumor which is arising from mesothelial cells and is associated with asbestos exposure. It is a heterogeneous cancer that shows a complex pattern of molecular changes, including genetic, chromosomic, and epigenetic abnormalities. The malignant pleural mesothelioma is characterized by a silent and slow clinical progression with an average period of 20–40 years from the asbestos exposure phase to the start of the symptoms. Unfortunately, to date, the therapeutic options are very limited, especially if the tumor is detected late. This narrative review provides an extended overview of the present evidence in the literature regarding the epidemiology, diagnostic pathways and treatment approaches of the malignant pleural mesothelioma. The treatment of mesothelioma has evolved slowly over the last 20 years not only from a surgical point of view but also radiotherapy, chemotherapy and immunotherapy play nowadays a key role. Several surgical strategies are available ranging from extrapleural pneumonectomy to cytoreductive surgery but a multidisciplinary approach seems to be mandatory because a single approach has not proved to date to be resolutive. New non-surgical treatment options appear to be promising but the results have to be taken in account with caution because clear evidence with high-quality studies is still lacking
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Affiliation(s)
| | - Gregor Kocher
- Division of General Thoracic Surgery, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Fabrizio Minervini
- Department of Thoracic Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
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13
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Tsim S, Cowell GW, Kidd A, Woodward R, Alexander L, Kelly C, Foster JE, Blyth KG. A comparison between MRI and CT in the assessment of primary tumour volume in mesothelioma. Lung Cancer 2020; 150:12-20. [PMID: 33039775 DOI: 10.1016/j.lungcan.2020.09.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 09/22/2020] [Accepted: 09/24/2020] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Primary tumour staging in Malignant Pleural Mesothelioma (MPM) using Computed Tomography (CT) imaging is confounded by perception errors reflecting low spatial resolution between tumour and adjacent structures. Augmentation using perfusion CT is constrained by radiation dosage. In this study, we evaluated an alternative tumour staging method using perfusion-tuned Magnetic Resonance Imaging (MRI). METHODS Consecutive patients with suspected MPM were recruited to a prospective observational study. All had MRI (T1-weighted, isotropic, contrast-enhanced 3-Tesla perfusion imaging) and CT (contrast-enhanced) pre-biopsy. Patients diagnosed with MPM underwent MRI and CT volumetry, with readers blinded to clinical data. MRI volumetry was semi-automated, using signal intensity limits from perfusion studies to grow tumour regions within a pleural volume. A similar CT method was not possible, therefore all visible tumour was manually segmented. MRI and CT volumes were compared (agreement, correlation, analysis time, reproducibility) and associations with survival examined using Cox regression. RESULTS 58 patients were recruited and had MRI before biopsy. 31/58 were diagnosed with MPM and these scans were used for volumetry. Mean (SD) MRI and CT volumes were 370 cm3 and 302 cm3, respectively. MRI volumes were larger (average bias 61.9 cm3 (SD 116), 95 % limits (-165.5 - 289 cm3), moderately correlated with CT (r = 0.56, p = 0.002) and independently associated with survival (HR 4.03 (95 % CI 1.5-11.55), p = 0.006). CT volumes were not associated with survival, took longer to compute than MRI volumes (mean (SD) 151 (19) v 14 (2) minutes, p=<0.0001) and were less reproducible (inter-observer ICC 0.72 for CT, 0.96 for MRI). CONCLUSIONS MRI and CT generate different tumour volumes in MPM. In this study, MRI volumes were larger and were independently associated with survival. MRI volumetry was quicker and more reproducible than CT.
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Affiliation(s)
- Selina Tsim
- Glasgow Pleural Disease Unit, Queen ElIzabeth University Hospital, Glasgow, United Kingdom
| | - Gordon W Cowell
- Imaging Department, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Andrew Kidd
- Glasgow Pleural Disease Unit, Queen ElIzabeth University Hospital, Glasgow, United Kingdom; Institute of Cancer Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Rosemary Woodward
- Clinical Research Imaging Facility, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Laura Alexander
- Cancer Research UK Clinical Trials Unit Glasgow, Institute of Cancer Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Caroline Kelly
- Cancer Research UK Clinical Trials Unit Glasgow, Institute of Cancer Sciences, University of Glasgow, Glasgow, United Kingdom
| | - John E Foster
- Clinical Research Imaging Facility, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Kevin G Blyth
- Glasgow Pleural Disease Unit, Queen ElIzabeth University Hospital, Glasgow, United Kingdom; Institute of Cancer Sciences, University of Glasgow, Glasgow, United Kingdom.
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14
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Sinha S, Swift AJ, Kamil MA, Matthews S, Bull MJ, Fisher P, De Fonseka D, Saha S, Edwards JG, Johns CS. The role of imaging in malignant pleural mesothelioma: an update after the 2018 BTS guidelines. Clin Radiol 2020; 75:423-432. [PMID: 32081346 DOI: 10.1016/j.crad.2019.12.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 12/04/2019] [Indexed: 02/07/2023]
Abstract
Malignant pleural mesothelioma (MPM) is a primary malignancy of the pleura and is associated with a poor outcome. The symptoms and signs of malignant mesothelioma present late in the natural history of the disease and are non-specific, making the diagnosis challenging and imaging key. In 2018, the British Thoracic Society (BTS) updated the guideline on diagnosis, staging, and follow-up of patients with MPM. These recommendations are discussed in this review of the current literature on imaging of MPM. It is estimated MPM will continue to cause serious morbidity and mortality in the UK late into the 21st century, and internationally, people continue to be exposed to asbestos. We aim to update the reader on current and future imaging strategies, which could aid early diagnosis of pleural malignancy and provide an update on staging and assessment of tumour response.
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Affiliation(s)
- S Sinha
- Department of Radiology, Sheffield Teaching Hospitals, Sheffield, UK
| | - A J Swift
- Department of Radiology, Sheffield Teaching Hospitals, Sheffield, UK; Academic Unit of Radiology, The University of Sheffield, Sheffield, UK
| | - M A Kamil
- Department of Radiology, Sheffield Teaching Hospitals, Sheffield, UK
| | - S Matthews
- Department of Radiology, Sheffield Teaching Hospitals, Sheffield, UK
| | - M J Bull
- Department of Radiology, Sheffield Teaching Hospitals, Sheffield, UK
| | - P Fisher
- Department of Oncology, Sheffield Teaching Hospitals, Sheffield, UK
| | - D De Fonseka
- Department of Respiratory Medicine, Sheffield Teaching Hospitals, Sheffield, UK
| | - S Saha
- Department of Respiratory Medicine, Sheffield Teaching Hospitals, Sheffield, UK
| | - J G Edwards
- Department of Thoracic Surgery, Sheffield Teaching Hospitals, Sheffield, UK
| | - C S Johns
- Department of Radiology, Sheffield Teaching Hospitals, Sheffield, UK.
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15
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Computed tomography features of local pleural recurrence in patients with malignant pleural mesothelioma treated with intensity-modulated pleural radiation therapy. Eur Radiol 2019; 29:3696-3704. [PMID: 30689034 DOI: 10.1007/s00330-018-5937-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 10/11/2018] [Accepted: 11/29/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVE This study was conducted in order to describe the computed tomography (CT) features of local pleural recurrence in patients with malignant pleural mesothelioma undergoing intensity-modulated pleural radiation therapy (IMPRINT) as part of multimodality treatment. METHODS In this observational study, 58 patients treated with IMPRINT between September 21, 2004, and December 1, 2014 were included. Baseline and follow-up CT scans were qualitatively assessed. On follow-up scans, pleural thickening was categorized as unchanged, decreased, or new/increased. New/increased pleural abnormality was subcategorized as diffuse smooth pleural thickening, diffuse nodular pleural thickening, focal pleural nodule, or multiple pleural nodules. To identify features more frequently present at the time of local recurrence, follow-up scans with local recurrence were matched to four control scans; exact conditional logistic regression was performed. RESULTS Twenty-one (36%) patients had local pleural recurrence and 20 (34%) patients had nonpleural recurrence; 3 patients had both types of recurrence. The 1-year cumulative incidence rate of local recurrence was 27% (95% confidence interval 15, 39). On follow-up scans, three patterns of pleural abnormality were significantly associated with local recurrence: new/increased multiple pleural nodules (10 (48%) positive scans vs 0 control scans), new/increased diffuse nodular pleural thickening (7 (33%) positive scans vs 1 (1%) control scans), and new/increased focal pleural nodule (3 (14%) positive scans vs 1 (1%) control scan) (p < 0.001 for all). CONCLUSIONS Multiple new/increased pleural nodules are the feature most commonly present at local recurrence following IMPRINT; however, any pattern of increased nodular pleural thickening is suspicious. KEY POINTS • In patients with mesothelioma receiving intensity-modulated pleural radiation as part of multimodality therapy, increasing multiple pleural nodules is the computed tomography feature most commonly present at local recurrence. • In these patients, any CT pattern of increased nodular pleural thickening should be considered suspicious for local recurrence. • The most common sites of nonpleural recurrence were lung parenchyma, thoracic lymph nodes, and peritoneum.
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16
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Tsim S, Humphreys CA, Cowell GW, Stobo DB, Noble C, Woodward R, Kelly CA, Alexander L, Foster JE, Dick C, Blyth KG. Early Contrast Enhancement: A novel magnetic resonance imaging biomarker of pleural malignancy. Lung Cancer 2018; 118:48-56. [PMID: 29572002 PMCID: PMC5884311 DOI: 10.1016/j.lungcan.2018.01.014] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Revised: 01/05/2018] [Accepted: 01/18/2018] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Pleural Malignancy (PM) is often occult on subjective radiological assessment. We sought to define a novel, semi-objective Magnetic Resonance Imaging (MRI) biomarker of PM, targeted to increased tumour microvessel density (MVD) and applicable to minimal pleural thickening. MATERIALS AND METHODS 60 consecutive patients with suspected PM underwent contrast-enhanced 3-T MRI then pleural biopsy. In 58/60, parietal pleura signal intensity (SI) was measured in multiple regions of interest (ROI) at multiple time-points, generating ROI SI/time curves and Mean SI gradient (MSIG: SI increment/time). The diagnostic performance of Early Contrast Enhancement (ECE; which was defined as a SI peak in at least one ROI at or before 4.5 min) was compared with subjective MRI and Computed Tomography (CT) morphology results. MSIG was correlated against tumour MVD (based on Factor VIII immunostain) in 31 patients with Mesothelioma. RESULTS 71% (41/58) patients had PM. Pleural thickening was <10 mm in 49/58 (84%). ECE sensitivity was 83% (95% CI 61-94%), specificity 83% (95% CI 68-91%), positive predictive value 68% (95% CI 47-84%), negative predictive value 92% (78-97%). ECE performance was similar or superior to subjective CT and MRI. MSIG correlated with MVD (r = 0.4258, p = .02). DISCUSSION ECE is a semi-objective, perfusion-based biomarker of PM, measurable in minimal pleural thickening. Further studies are warranted.
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Affiliation(s)
- Selina Tsim
- Pleural Disease Unit, Queen Elizabeth University Hospital, Glasgow, UK; Institute of Cancer Sciences, University of Glasgow, UK
| | | | - Gordon W Cowell
- Department of Radiology, Queen Elizabeth University Hospital, Glasgow, UK
| | - David B Stobo
- Department of Radiology, Queen Elizabeth University Hospital, Glasgow, UK
| | - Colin Noble
- Department of Radiology, Glasgow Royal Infirmary, Glasgow, UK
| | - Rosemary Woodward
- Clinical Research Imaging Facility, Queen Elizabeth University Hospital, Glasgow, UK
| | - Caroline A Kelly
- Cancer Research UK Clinical Trials Unit, Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - Laura Alexander
- Cancer Research UK Clinical Trials Unit, Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - John E Foster
- Clinical Research Imaging Facility, Queen Elizabeth University Hospital, Glasgow, UK
| | - Craig Dick
- Department of Pathology, Queen Elizabeth University Hospital, Glasgow, UK
| | - Kevin G Blyth
- Pleural Disease Unit, Queen Elizabeth University Hospital, Glasgow, UK; Institute of Infection, Immunity & Inflammmation, University of Glasgow, UK.
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17
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Elliott HS, Metser U, de Perrot M, Cho J, Bradbury P, Veit-Haibach P, Hussey D, Noam T. 18F-FDG PET/CT in the management of patients with malignant pleural mesothelioma being considered for multimodality therapy: experience of a tertiary referral center. Br J Radiol 2018; 91:20170814. [PMID: 29498536 DOI: 10.1259/bjr.20170814] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE To compare the N- and M-staging accuracy of PET vs CT, as per the American Joint Committee on Cancer (AJCC) eighth edition in patients with malignant pleural mesothelioma (MPM) being considered for multimodality therapy in a tertiary referral center. A secondary aim was to assess survival outcome of patients chosen for surgical management after PET. METHODS A retrospective, single institution comparison of PET and CT was performed in patients with histologically proven MPM being considered for multimodality therapy. Performance of each modality in identifying nodal category and presence or absence of distant metastases was abstracted from electronic patient records. The standard of reference was surgical histopathology for nodal stage and histopathology or clinical and imaging follow-up of >3 months for distant metastases. RESULTS There were 101 eligible patients with complete data sets; 82 males, 19 females with a mean age of 66.6 years (range: 39-85). Most patients (n = 68) had epithelioid histology. Surgery was performed in 61/101 patients (60.4%), most of whom had multimodality therapy. Nodal category was concordant to surgical histopathology in 38/60 patients (63.3%) on PET, compared to 27/60 (45%) on CT (p = 0.001). For detection of ≥N1 disease only, PET and CT correctly staged 15/37 patients (40.5%) and 8/37 (21.6%), respectively (p = 0.023). Distant metastases were identified uniquely on PET in eight patients and on CT only in one patient. Overall, PET and CT correctly identified 11/12 (91.6%) and 4/12 (33.3%) patients with distant metastases, respectively (p = 0.0391). CONCLUSION PET identifies significantly more patients with nodal or distant metastatic disease than CT and may contribute to more appropriate selection of patients with MPM for surgery or multimodality therapy. Advances in knowledge: In patients with MPM, fludeoxyglucose-PET/CT detects significantly more patients with distant metastases than CT. PET/CT can help in the selection of patients with MPM who would benefit from surgery or multimodality therapy.
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Affiliation(s)
- Hugh S Elliott
- 1 Joint Department of Medical Imaging, Princess Margaret Cancer Centre, University Health Network, Mount Sinai Hospital and Women's College Hospital, University of Toronto , Toronto, ON , Canada
| | - Ur Metser
- 1 Joint Department of Medical Imaging, Princess Margaret Cancer Centre, University Health Network, Mount Sinai Hospital and Women's College Hospital, University of Toronto , Toronto, ON , Canada
| | - Marc de Perrot
- 2 Division of Thoracic Surgery, Princess Margaret Cancer Centre and Toronto General Hospital, University Health Network, University of Toronto , Toronto, ON , Canada
| | - John Cho
- 3 Department of Radiation Oncology, Princess Margaret Cancer Centre and Toronto General Hospital, University Health Network, University of Toronto , Toronto, ON , Canada
| | - Penelope Bradbury
- 4 Division of Medical Oncology, Princess Margaret Cancer Centre and Toronto General Hospital, University Health Network, University of Toronto , Toronto, ON , Canada
| | - Patrick Veit-Haibach
- 1 Joint Department of Medical Imaging, Princess Margaret Cancer Centre, University Health Network, Mount Sinai Hospital and Women's College Hospital, University of Toronto , Toronto, ON , Canada
| | - Douglas Hussey
- 1 Joint Department of Medical Imaging, Princess Margaret Cancer Centre, University Health Network, Mount Sinai Hospital and Women's College Hospital, University of Toronto , Toronto, ON , Canada
| | - Tau Noam
- 1 Joint Department of Medical Imaging, Princess Margaret Cancer Centre, University Health Network, Mount Sinai Hospital and Women's College Hospital, University of Toronto , Toronto, ON , Canada
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18
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Woolhouse I, Bishop L, Darlison L, De Fonseka D, Edey A, Edwards J, Faivre-Finn C, Fennell DA, Holmes S, Kerr KM, Nakas A, Peel T, Rahman NM, Slade M, Steele J, Tsim S, Maskell NA. British Thoracic Society Guideline for the investigation and management of malignant pleural mesothelioma. Thorax 2018; 73:i1-i30. [PMID: 29444986 DOI: 10.1136/thoraxjnl-2017-211321] [Citation(s) in RCA: 125] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Ian Woolhouse
- Department of Respiratory Medicine, University Hospitals Birmingham, NHS Foundation Trust, Birmingham, UK
| | - Lesley Bishop
- Department of Respiratory Medicine, University Hospitals Birmingham, NHS Foundation Trust, Birmingham, UK
| | - Liz Darlison
- Respiratory Medicine, University Hospitals of Leicester, Leicester, UK
| | | | | | | | | | - Dean A Fennell
- University of Leicester & University Hospitals of Leicester, Leicester, UK
| | - Steve Holmes
- The Park Medical Practice, Shepton Mallet, Somerset, UK
| | | | - Apostolos Nakas
- Department of Thoracic Surgery, Glenfield Hospital, Leicester, UK
| | - Tim Peel
- North Tyneside General Hospital, North Shields, UK
| | - Najib M Rahman
- Oxford NIHR Biomedical Research, University of Oxford, Oxford, UK
| | - Mark Slade
- Papworth Hospital, Thoracic Oncology, Cambridge, UK
| | | | - Selina Tsim
- Respiratory Medicine, Queen Elizabeth University Hospital, Glasgow, UK
| | - Nick A Maskell
- Academic Respiratory Unit, Bristol Medical School, University of Bristol, Bristol, UK
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Kindler HL, Ismaila N, Armato SG, Bueno R, Hesdorffer M, Jahan T, Jones CM, Miettinen M, Pass H, Rimner A, Rusch V, Sterman D, Thomas A, Hassan R. Treatment of Malignant Pleural Mesothelioma: American Society of Clinical Oncology Clinical Practice Guideline. J Clin Oncol 2018; 36:1343-1373. [PMID: 29346042 DOI: 10.1200/jco.2017.76.6394] [Citation(s) in RCA: 262] [Impact Index Per Article: 43.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Purpose To provide evidence-based recommendations to practicing physicians and others on the management of malignant pleural mesothelioma. Methods ASCO convened an Expert Panel of medical oncology, thoracic surgery, radiation oncology, pulmonary, pathology, imaging, and advocacy experts to conduct a literature search, which included systematic reviews, meta-analyses, randomized controlled trials, and prospective and retrospective comparative observational studies published from 1990 through 2017. Outcomes of interest included survival, disease-free or recurrence-free survival, and quality of life. Expert Panel members used available evidence and informal consensus to develop evidence-based guideline recommendations. Results The literature search identified 222 relevant studies to inform the evidence base for this guideline. Recommendations Evidence-based recommendations were developed for diagnosis, staging, chemotherapy, surgical cytoreduction, radiation therapy, and multimodality therapy in patients with malignant pleural mesothelioma. Additional information is available at www.asco.org/thoracic-cancer-guidelines and www.asco.org/guidelineswiki .
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Affiliation(s)
- Hedy L Kindler
- Hedy L. Kindler and Samuel G. Armato III, The University of Chicago, Chicago, IL; Nofisat Ismaila, American Society of Clinical Oncology; Mary Hesdorffer, Mesothelioma Applied Research Foundation, Alexandria, VA; Raphael Bueno, Harvard Medical School, Boston, MA; Thierry Jahan, University of California San Francisco, San Francisco, CA; Clyde Michael Jones, Baptist Cancer Center Physicians Foundation, Memphis, TN; Markku Miettinen, Anish Thomas and Raffit Hassan, Center for Cancer Research, National Cancer Institute, Bethesda, MD; Harvey Pass and Daniel Sterman, New York University Langone Medical Center; and Andreas Rimner and Valerie Rusch, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Nofisat Ismaila
- Hedy L. Kindler and Samuel G. Armato III, The University of Chicago, Chicago, IL; Nofisat Ismaila, American Society of Clinical Oncology; Mary Hesdorffer, Mesothelioma Applied Research Foundation, Alexandria, VA; Raphael Bueno, Harvard Medical School, Boston, MA; Thierry Jahan, University of California San Francisco, San Francisco, CA; Clyde Michael Jones, Baptist Cancer Center Physicians Foundation, Memphis, TN; Markku Miettinen, Anish Thomas and Raffit Hassan, Center for Cancer Research, National Cancer Institute, Bethesda, MD; Harvey Pass and Daniel Sterman, New York University Langone Medical Center; and Andreas Rimner and Valerie Rusch, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Samuel G Armato
- Hedy L. Kindler and Samuel G. Armato III, The University of Chicago, Chicago, IL; Nofisat Ismaila, American Society of Clinical Oncology; Mary Hesdorffer, Mesothelioma Applied Research Foundation, Alexandria, VA; Raphael Bueno, Harvard Medical School, Boston, MA; Thierry Jahan, University of California San Francisco, San Francisco, CA; Clyde Michael Jones, Baptist Cancer Center Physicians Foundation, Memphis, TN; Markku Miettinen, Anish Thomas and Raffit Hassan, Center for Cancer Research, National Cancer Institute, Bethesda, MD; Harvey Pass and Daniel Sterman, New York University Langone Medical Center; and Andreas Rimner and Valerie Rusch, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Raphael Bueno
- Hedy L. Kindler and Samuel G. Armato III, The University of Chicago, Chicago, IL; Nofisat Ismaila, American Society of Clinical Oncology; Mary Hesdorffer, Mesothelioma Applied Research Foundation, Alexandria, VA; Raphael Bueno, Harvard Medical School, Boston, MA; Thierry Jahan, University of California San Francisco, San Francisco, CA; Clyde Michael Jones, Baptist Cancer Center Physicians Foundation, Memphis, TN; Markku Miettinen, Anish Thomas and Raffit Hassan, Center for Cancer Research, National Cancer Institute, Bethesda, MD; Harvey Pass and Daniel Sterman, New York University Langone Medical Center; and Andreas Rimner and Valerie Rusch, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Mary Hesdorffer
- Hedy L. Kindler and Samuel G. Armato III, The University of Chicago, Chicago, IL; Nofisat Ismaila, American Society of Clinical Oncology; Mary Hesdorffer, Mesothelioma Applied Research Foundation, Alexandria, VA; Raphael Bueno, Harvard Medical School, Boston, MA; Thierry Jahan, University of California San Francisco, San Francisco, CA; Clyde Michael Jones, Baptist Cancer Center Physicians Foundation, Memphis, TN; Markku Miettinen, Anish Thomas and Raffit Hassan, Center for Cancer Research, National Cancer Institute, Bethesda, MD; Harvey Pass and Daniel Sterman, New York University Langone Medical Center; and Andreas Rimner and Valerie Rusch, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Thierry Jahan
- Hedy L. Kindler and Samuel G. Armato III, The University of Chicago, Chicago, IL; Nofisat Ismaila, American Society of Clinical Oncology; Mary Hesdorffer, Mesothelioma Applied Research Foundation, Alexandria, VA; Raphael Bueno, Harvard Medical School, Boston, MA; Thierry Jahan, University of California San Francisco, San Francisco, CA; Clyde Michael Jones, Baptist Cancer Center Physicians Foundation, Memphis, TN; Markku Miettinen, Anish Thomas and Raffit Hassan, Center for Cancer Research, National Cancer Institute, Bethesda, MD; Harvey Pass and Daniel Sterman, New York University Langone Medical Center; and Andreas Rimner and Valerie Rusch, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Clyde Michael Jones
- Hedy L. Kindler and Samuel G. Armato III, The University of Chicago, Chicago, IL; Nofisat Ismaila, American Society of Clinical Oncology; Mary Hesdorffer, Mesothelioma Applied Research Foundation, Alexandria, VA; Raphael Bueno, Harvard Medical School, Boston, MA; Thierry Jahan, University of California San Francisco, San Francisco, CA; Clyde Michael Jones, Baptist Cancer Center Physicians Foundation, Memphis, TN; Markku Miettinen, Anish Thomas and Raffit Hassan, Center for Cancer Research, National Cancer Institute, Bethesda, MD; Harvey Pass and Daniel Sterman, New York University Langone Medical Center; and Andreas Rimner and Valerie Rusch, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Markku Miettinen
- Hedy L. Kindler and Samuel G. Armato III, The University of Chicago, Chicago, IL; Nofisat Ismaila, American Society of Clinical Oncology; Mary Hesdorffer, Mesothelioma Applied Research Foundation, Alexandria, VA; Raphael Bueno, Harvard Medical School, Boston, MA; Thierry Jahan, University of California San Francisco, San Francisco, CA; Clyde Michael Jones, Baptist Cancer Center Physicians Foundation, Memphis, TN; Markku Miettinen, Anish Thomas and Raffit Hassan, Center for Cancer Research, National Cancer Institute, Bethesda, MD; Harvey Pass and Daniel Sterman, New York University Langone Medical Center; and Andreas Rimner and Valerie Rusch, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Harvey Pass
- Hedy L. Kindler and Samuel G. Armato III, The University of Chicago, Chicago, IL; Nofisat Ismaila, American Society of Clinical Oncology; Mary Hesdorffer, Mesothelioma Applied Research Foundation, Alexandria, VA; Raphael Bueno, Harvard Medical School, Boston, MA; Thierry Jahan, University of California San Francisco, San Francisco, CA; Clyde Michael Jones, Baptist Cancer Center Physicians Foundation, Memphis, TN; Markku Miettinen, Anish Thomas and Raffit Hassan, Center for Cancer Research, National Cancer Institute, Bethesda, MD; Harvey Pass and Daniel Sterman, New York University Langone Medical Center; and Andreas Rimner and Valerie Rusch, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Andreas Rimner
- Hedy L. Kindler and Samuel G. Armato III, The University of Chicago, Chicago, IL; Nofisat Ismaila, American Society of Clinical Oncology; Mary Hesdorffer, Mesothelioma Applied Research Foundation, Alexandria, VA; Raphael Bueno, Harvard Medical School, Boston, MA; Thierry Jahan, University of California San Francisco, San Francisco, CA; Clyde Michael Jones, Baptist Cancer Center Physicians Foundation, Memphis, TN; Markku Miettinen, Anish Thomas and Raffit Hassan, Center for Cancer Research, National Cancer Institute, Bethesda, MD; Harvey Pass and Daniel Sterman, New York University Langone Medical Center; and Andreas Rimner and Valerie Rusch, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Valerie Rusch
- Hedy L. Kindler and Samuel G. Armato III, The University of Chicago, Chicago, IL; Nofisat Ismaila, American Society of Clinical Oncology; Mary Hesdorffer, Mesothelioma Applied Research Foundation, Alexandria, VA; Raphael Bueno, Harvard Medical School, Boston, MA; Thierry Jahan, University of California San Francisco, San Francisco, CA; Clyde Michael Jones, Baptist Cancer Center Physicians Foundation, Memphis, TN; Markku Miettinen, Anish Thomas and Raffit Hassan, Center for Cancer Research, National Cancer Institute, Bethesda, MD; Harvey Pass and Daniel Sterman, New York University Langone Medical Center; and Andreas Rimner and Valerie Rusch, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Daniel Sterman
- Hedy L. Kindler and Samuel G. Armato III, The University of Chicago, Chicago, IL; Nofisat Ismaila, American Society of Clinical Oncology; Mary Hesdorffer, Mesothelioma Applied Research Foundation, Alexandria, VA; Raphael Bueno, Harvard Medical School, Boston, MA; Thierry Jahan, University of California San Francisco, San Francisco, CA; Clyde Michael Jones, Baptist Cancer Center Physicians Foundation, Memphis, TN; Markku Miettinen, Anish Thomas and Raffit Hassan, Center for Cancer Research, National Cancer Institute, Bethesda, MD; Harvey Pass and Daniel Sterman, New York University Langone Medical Center; and Andreas Rimner and Valerie Rusch, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Anish Thomas
- Hedy L. Kindler and Samuel G. Armato III, The University of Chicago, Chicago, IL; Nofisat Ismaila, American Society of Clinical Oncology; Mary Hesdorffer, Mesothelioma Applied Research Foundation, Alexandria, VA; Raphael Bueno, Harvard Medical School, Boston, MA; Thierry Jahan, University of California San Francisco, San Francisco, CA; Clyde Michael Jones, Baptist Cancer Center Physicians Foundation, Memphis, TN; Markku Miettinen, Anish Thomas and Raffit Hassan, Center for Cancer Research, National Cancer Institute, Bethesda, MD; Harvey Pass and Daniel Sterman, New York University Langone Medical Center; and Andreas Rimner and Valerie Rusch, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Raffit Hassan
- Hedy L. Kindler and Samuel G. Armato III, The University of Chicago, Chicago, IL; Nofisat Ismaila, American Society of Clinical Oncology; Mary Hesdorffer, Mesothelioma Applied Research Foundation, Alexandria, VA; Raphael Bueno, Harvard Medical School, Boston, MA; Thierry Jahan, University of California San Francisco, San Francisco, CA; Clyde Michael Jones, Baptist Cancer Center Physicians Foundation, Memphis, TN; Markku Miettinen, Anish Thomas and Raffit Hassan, Center for Cancer Research, National Cancer Institute, Bethesda, MD; Harvey Pass and Daniel Sterman, New York University Langone Medical Center; and Andreas Rimner and Valerie Rusch, Memorial Sloan Kettering Cancer Center, New York, NY
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20
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Qin KR, Dua D. Diagnostic Dilemma: Primary Peritoneal Mesothelioma With Para-Occupational Asbestos Exposure. J Glob Oncol 2017; 3:828-832. [PMID: 29244982 PMCID: PMC5735958 DOI: 10.1200/jgo.2016.005280] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Kirby R Qin
- Kirby R. Qin, Monash University; Divyanshu Dua, Mildura Base Hospital, Victoria, Australia
| | - Divyanshu Dua
- Kirby R. Qin, Monash University; Divyanshu Dua, Mildura Base Hospital, Victoria, Australia
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Odisio EG, Marom EM, Shroff GS, Wu CC, Benveniste APA, Truong MT, Benveniste MF. Malignant Pleural Mesothelioma: Diagnosis, Staging, Pitfalls and Follow-up. Semin Ultrasound CT MR 2017; 38:559-570. [DOI: 10.1053/j.sult.2017.07.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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22
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Blyth KG, Murphy DJ. Progress and challenges in Mesothelioma: From bench to bedside. Respir Med 2017; 134:31-41. [PMID: 29413505 DOI: 10.1016/j.rmed.2017.11.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 11/03/2017] [Accepted: 11/24/2017] [Indexed: 12/19/2022]
Abstract
Malignant Pleural Mesothelioma (MPM) is currently an incurable cancer with a typical survival of 1 year from the time of diagnosis. The recent genomic and transcriptomic characterization of MPM presents new opportunities and challenges for MPM researchers. Recent advances in clinical and laboratory diagnostics, and proposals for an updated, data-driven, staging system, also present new challenges for clinicians and hospital services involved in MPM care. The aim of this review is first to introduce the reader to the topic of MPM, a disease that is causally linked to prior, typically occupational, exposure to asbestos fibres. Secondly, we will discuss MPM from the clinical and laboratory perspectives, including reviews of current and evolving therapies and our present understanding of the molecular basis of the disease. Finally, we will attempt to identify critical knowledge gaps that currently prevent more effective treatment, including the challenges involved in early detection and chemoprophylaxis.
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Affiliation(s)
- Kevin G Blyth
- Glasgow Pleural Disease Unit, Queen Elizabeth University Hospital, Glasgow, UK; Institute of Infection, Immunity and Inflammation, University of Glasgow, UK.
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Abstract
Mesothelioma is an aggressive cancer of pleural and peritoneal cells that is difficult to diagnose and monitor. Numerous studies have attempted to identify a blood- or pleural fluid-based biomarker that could be used in the diagnostic pathway. More recently, there has been interest in the ability of serum/plasma biomarkers to monitor mesothelioma, given the development of newer treatments and limitations of radiological assessment. The majority of research has focused on soluble mesothelin, a soluble glycoprotein expressed by mesothelial cells. Although soluble mesothelin lacks the sensitivity to be used as a standalone diagnostic marker, serial measurements may be informative, with rising concentrations indicating disease progression and poor survival. High concentrations of other soluble glycoproteins, such as osteopontin, fibulin-3 and vascular endothelial growth factor are independently associated with poor prognosis at baseline, although further research is required to ascertain any role outside of clinical trials. More recent literature has focused on the development of novel biomarkers from discovery cohorts. Although many DNA and mRNA biomarkers show promise in the diagnosis or screening of mesothelioma, none have been prospectively evaluated for use in clinical practice. In this review article, we highlight the potential utility of biomarkers and evaluate the existing literature.
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Affiliation(s)
- David T Arnold
- Academic Respiratory Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Nick A Maskell
- Academic Respiratory Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
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24
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Bonomi M, De Filippis C, Lopci E, Gianoncelli L, Rizzardi G, Cerchiaro E, Bortolotti L, Zanello A, Ceresoli GL. Clinical staging of malignant pleural mesothelioma: current perspectives. LUNG CANCER-TARGETS AND THERAPY 2017; 8:127-139. [PMID: 28860886 PMCID: PMC5571821 DOI: 10.2147/lctt.s102113] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Malignant pleural mesothelioma (MPM) is a disease with limited therapeutic options, the management of which is still controversial. Diagnosis is usually made by thoracoscopy, which allows multiple biopsies with histological subtyping and is indicated for staging purposes in surgical candidates. The recommended and recently updated classification for clinical use is the TNM staging system established by the International Mesothelioma Interest Group and the International Association for the Study of Lung Cancer, which is based mainly on surgical and pathological variables, as well as on cross-sectional imaging. Contrast-enhanced computed tomography is the primary imaging procedure. Currently, the most used measurement system for MPM is the modified Response Evaluation Criteria in Solid Tumors (RECIST) method, which is based on unidimensional measurements of tumor thickness perpendicular to the chest wall or mediastinum. Magnetic resonance imaging and functional imaging with 18F-fluoro-2-deoxy-D-glucose positron-emission tomography can provide additional staging information in selected cases, although the usefulness of this method is limited in patients undergoing pleurodesis. Molecular reclassification of MPM and gene expression or miRNA prognostic models have the potential to improve prognostication and patient selection for a proper treatment algorithm; however, they await prospective validation to be introduced in clinical practice.
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Affiliation(s)
- Maria Bonomi
- Department of Oncology, Thoracic and GU Oncology Unit
| | | | - Egesta Lopci
- Nuclear Medicine Unit, Humanitas Clinical and Research Hospital, Milan
| | | | - Giovanna Rizzardi
- Department of Thoracic Surgery, Cliniche Humanitas Gavazzeni, Bergamo, Italy
| | | | - Luigi Bortolotti
- Department of Thoracic Surgery, Cliniche Humanitas Gavazzeni, Bergamo, Italy
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25
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Murphy DJ, Gill RR. Volumetric assessment in malignant pleural mesothelioma. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:241. [PMID: 28706909 DOI: 10.21037/atm.2017.05.23] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Malignant pleural mesothelioma (MPM) is a highly malignant pleural neoplasm with a dismal prognosis. Multimodality approach including surgery and chemotherapy are utilized to treat patients with resectable disease. Clinical staging allows for selection of patients for treatment strategies, but has not been found to be prognostic and is plagued by high interobserver variability. Tumor volume measurement on cross-sectional imaging has emerged as a potential quantitative tool with prognostic significance. This review focuses on volumetric assessment from cross-sectional imaging (CT, MRI, 18F-FDG PET/CT) and the potential prognostic benefit and applications.
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Affiliation(s)
- David J Murphy
- Division of Thoracic Imaging, Department of Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Ritu R Gill
- Division of Thoracic Imaging, Department of Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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26
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Bibby AC, Tsim S, Kanellakis N, Ball H, Talbot DC, Blyth KG, Maskell NA, Psallidas I. Malignant pleural mesothelioma: an update on investigation, diagnosis and treatment. Eur Respir Rev 2017; 25:472-486. [PMID: 27903668 PMCID: PMC9487555 DOI: 10.1183/16000617.0063-2016] [Citation(s) in RCA: 181] [Impact Index Per Article: 25.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 10/12/2016] [Indexed: 02/06/2023] Open
Abstract
Malignant pleural mesothelioma is an aggressive malignancy of the pleural surface, predominantly caused by prior asbestos exposure. There is a global epidemic of malignant pleural mesothelioma underway, and incidence rates are predicted to peak in the next few years. This article summarises the epidemiology and pathogenesis of malignant pleural mesothelioma, before describing some key factors in the patient experience and outlining common symptoms. Diagnostic approaches are reviewed, including imaging techniques and the role of various biomarkers. Treatment options are summarised, including the importance of palliative care and methods of controlling pleural effusions. The evidence for chemotherapy, radiotherapy and surgery is reviewed, both in the palliative setting and in the context of trimodality treatment. An algorithm for managing malignant pleural effusion in malignant pleural mesothelioma patients is presented. Finally new treatment developments and novel therapeutic approaches are summarised. This article on mesothelioma describes pathogenesis, symptoms, diagnostic approaches and treatment optionshttp://ow.ly/cjkb305aQGz
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Affiliation(s)
- Anna C Bibby
- Academic Respiratory Unit, University of Bristol, Bristol ,UK .,North Bristol NHS Trust, Bristol, UK
| | - Selina Tsim
- Queen Elizabeth University Hospital, Glasgow, UK.,Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - Nikolaos Kanellakis
- Respiratory Trials Unit, University of Oxford, Churchill Hospital, Oxford, UK.,Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford, UK
| | - Hannah Ball
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford, UK.,Dept of Oncology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Denis C Talbot
- Dept of Oncology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Kevin G Blyth
- Queen Elizabeth University Hospital, Glasgow, UK.,Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
| | - Nick A Maskell
- Academic Respiratory Unit, University of Bristol, Bristol ,UK.,North Bristol NHS Trust, Bristol, UK
| | - Ioannis Psallidas
- Respiratory Trials Unit, University of Oxford, Churchill Hospital, Oxford, UK.,Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford, UK
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Value of contrast CT in combination with PET/CT in mesothelioma staging: Optimal protocol for initial assessment. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2017. [DOI: 10.1016/j.ejrnm.2016.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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28
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Present and future roles of FDG-PET/CT imaging in the management of malignant pleural mesothelioma. Jpn J Radiol 2016; 34:537-47. [PMID: 27222020 DOI: 10.1007/s11604-016-0555-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Accepted: 05/12/2016] [Indexed: 12/11/2022]
Abstract
Positron emission tomography/computed tomography (PET/CT) integrated with 2-[(18)F]fluoro-2-deoxy-D-glucose ((18)F-FDG) has emerged as a powerful tool for combined metabolic and anatomic evaluations in clinical oncologic imaging. This review discusses the utility of (18)F-FDG PET/CT as a tool to manage patients with malignant pleural mesothelioma. We discuss different stages of patient management in malignant pleural mesothelioma, including diagnosis, initial staging, therapy planning, early treatment response assessment, re-staging, and prognosis.
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29
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Diagnostic accuracy of sequential co-registered PET+MR in comparison to PET/CT in local thoracic staging of malignant pleural mesothelioma. Lung Cancer 2016; 94:40-5. [DOI: 10.1016/j.lungcan.2016.01.017] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2015] [Revised: 01/22/2016] [Accepted: 01/24/2016] [Indexed: 11/23/2022]
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Abstract
(18)Fluorine-2-fluoro-2-Deoxy-d-glucose ((18)F-FDG) positron emission tomography/computerized tomography (PET/CT) is a well-established functional imaging method widely used in oncology. In this article, we have incorporated the various indications for (18)FDG PET/CT in oncology based on available evidence and current guidelines. Growing body of evidence for use of (18)FDG PET/CT in select tumors is also discussed. This article attempts to give the reader an overview of the appropriateness of using (18)F-FDG PET/CT in various malignancies.
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Affiliation(s)
- Archi Agrawal
- Department of Nuclear Medicine and Molecular Imaging, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Venkatesh Rangarajan
- Department of Nuclear Medicine and Molecular Imaging, Tata Memorial Hospital, Mumbai, Maharashtra, India
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P. FR. ASPECTOS DIAGNÓSTICOS Y TERAPÉUTICOS EN EL MESOTELIOMA PLEURAL MALIGNO. REVISTA MÉDICA CLÍNICA LAS CONDES 2015. [DOI: 10.1016/j.rmclc.2015.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Use of Computed Tomography and Positron Emission Tomography/Computed Tomography for Staging of Local Extent in Patients With Malignant Pleural Mesothelioma. J Comput Assist Tomogr 2015; 39:160-5. [DOI: 10.1097/rct.0000000000000174] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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35
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Gunduz S, Mutlu H, Goksu SS, Arslan D, Tatli AM, Uysal M, Coskun HS, Bozcuk H, Ozdogan M, Savas B. Oral cyclophosphamide and etoposide in treatment of malignant pleural mesothelioma. Asian Pac J Cancer Prev 2014; 15:8843-6. [PMID: 25374217 DOI: 10.7314/apjcp.2014.15.20.8843] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Malignant mesothelioma (MM) is almost always fatal and few treatment options are available. The aim of this study was to evaluate the efficacy of oral cyclophosphamide and etoposide for patients who underwent standard treatment for advanced MM. MATERIALS AND METHODS This study included 22 malignant pleural mesothelioma patients who were treated with oral cyclophosphamide and etoposide (EE). RESULTS The average follow-up period of the patients was 39.1 months. Under the treatment of oral EE, median progression- free survival was 7.7 months [95%CI HR (4.3-11.1)] and median overall survival was 28.1 months [95%CI HR (5.8-50.3)]. The treatment response rates were as follows: 4 patients (27.3%) had a partial response (PR), 12 (54.5%) had stable disease (SD), and progressive disease (PD) was observed in 6 (35.9%). CONCLUSIONS Oral EE can be administered effectively to patients with inoperable malignant mesothelioma who had previously received standard treatments.
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Affiliation(s)
- Seyda Gunduz
- Department of Medical Oncology, Antalya Education and Research Hospital, Antalya, Turkey E-mail :
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Nickell LT, Lichtenberger JP, Khorashadi L, Abbott GF, Carter BW. Multimodality Imaging for Characterization, Classification, and Staging of Malignant Pleural Mesothelioma. Radiographics 2014; 34:1692-706. [DOI: 10.1148/rg.346130089] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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37
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Ai J, Stevenson JP. Current issues in malignant pleural mesothelioma evaluation and management. Oncologist 2014; 19:975-84. [PMID: 25061089 PMCID: PMC4153452 DOI: 10.1634/theoncologist.2014-0122] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2014] [Accepted: 06/11/2014] [Indexed: 01/09/2023] Open
Abstract
Malignant pleural mesothelioma (MPM) is an uncommon disease most often associated with occupational asbestos exposure and is steadily increasing in worldwide incidence. Patients typically present at an older age, with advanced clinical stage and other medical comorbidities, making management quite challenging. Despite great efforts, the prognosis of MPM remains poor, especially at progression after initial treatment. Macroscopic complete resection of MPM can be achieved through extrapleural pneumonectomy (EPP) or extended (ie, radical) pleurectomy (e-P/D) in selected patients and can result in prolonged survival when incorporated into a multimodality approach. Given the morbidity associated with surgical resection of MPM, optimizing identification of appropriate patients is essential. Unfortunately, most patients are not candidates for EPP or e-P/D due to advanced stage, age, and/or medical comorbidity. Pemetrexed and platinum combination chemotherapy has become the cornerstone of therapy for patients with unresectable disease because the combination is associated with improved survival and quality of life in treated patients. However, MPM eventually becomes resistant to initial therapy, and benefit to further lines of therapy has not been substantiated in randomized clinical trials. Translational research has provided exciting insights into tumorigenesis, biomarkers, and immune response in MPM, leading to the development of multiple novel therapeutic agents that are currently in clinical trials. These advances hold the promise of a new era in the treatment of MPM and suggest that this disease will not be left behind in the war on cancer.
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Affiliation(s)
- Jing Ai
- Cleveland Clinic Foundation, Taussig Cancer Institute, Cleveland, Ohio, USA
| | - James P Stevenson
- Cleveland Clinic Foundation, Taussig Cancer Institute, Cleveland, Ohio, USA
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Rodríguez Panadero F. Diagnosis and treatment of malignant pleural mesothelioma. Arch Bronconeumol 2014; 51:177-84. [PMID: 25059587 DOI: 10.1016/j.arbres.2014.06.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2014] [Revised: 06/10/2014] [Accepted: 06/10/2014] [Indexed: 12/26/2022]
Abstract
There are three major challenges in the diagnosis of malignant pleural mesothelioma: mesothelioma must be distinguished from benign mesothelial hyperplasia; malignant mesothelioma (and its subtypes) must be distinguished from metastatic carcinoma; and invasion of structures adjacent to the pleura must be demonstrated. The basis for clarifying the first two aspects is determination of a panel of monoclonal antibodies with appropriate immunohistochemical evaluation performed by highly qualified experts. Clarification of the third aspect requires sufficiently abundant, deep biopsy material, for which thoracoscopy is the technique of choice. Video-assisted needle biopsy with real-time imaging can be of great assistance when there is diffuse nodal thickening and scant or absent effusion. Given the difficulties of reaching an early diagnosis, cure is not generally achieved with radical surgery (pleuropneumonectomy), so liberation of the tumor mass with pleurectomy/decortication combined with chemo- or radiation therapy (multimodal treatment) has been gaining followers in recent years. In cases in which surgery is not feasible, chemotherapy (a combination of pemetrexed and platinum-derived compounds, in most cases) with pleurodesis or a tunneled pleural drainage catheter, if control of pleural effusion is required, can be considered. Radiation therapy is reserved for treatment of pain associated with infiltration of the chest wall or any other neighboring structure. In any case, comprehensive support treatment for pain control in specialist units is essential: this acquires particular significance in this type of malignancy.
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Affiliation(s)
- Francisco Rodríguez Panadero
- Instituto de Biomedicina de Sevilla (IBiS), Unidad Médico-Quirúrgica de Enfermedades Respiratorias (UMQER), Hospital Universitario Virgen del Rocío, CSIC, Universidad de Sevilla, Sevilla, España CIBER de Enfermedades Respiratorias (CIBERES), I.S. Carlos III, Madrid, España.
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Truong MT, Viswanathan C, Godoy MBC, Carter BW, Marom EM. Malignant pleural mesothelioma: role of CT, MRI, and PET/CT in staging evaluation and treatment considerations. Semin Roentgenol 2014; 48:323-34. [PMID: 24034264 DOI: 10.1053/j.ro.2013.03.017] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Mylene T Truong
- Department of Diagnostic Radiology, Division of Diagnostic Imaging, University of Texas, M.D. Anderson Cancer Center, Houston, TX.
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van Thiel ERE, Surmont VF, van Meerbeeck JP. Malignant pleural mesothelioma: when is radiation therapy indicated? Expert Rev Anticancer Ther 2014; 11:551-60. [DOI: 10.1586/era.10.169] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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van Zandwijk N, Clarke C, Henderson D, Musk AW, Fong K, Nowak A, Loneragan R, McCaughan B, Boyer M, Feigen M, Currow D, Schofield P, Nick Pavlakis BI, McLean J, Marshall H, Leong S, Keena V, Penman A. Guidelines for the diagnosis and treatment of malignant pleural mesothelioma. J Thorac Dis 2013; 5:E254-307. [PMID: 24416529 PMCID: PMC3886874 DOI: 10.3978/j.issn.2072-1439.2013.11.28] [Citation(s) in RCA: 81] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Accepted: 11/25/2013] [Indexed: 12/24/2022]
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Remon J, Lianes P, Martínez S, Velasco M, Querol R, Zanui M. Malignant mesothelioma: New insights into a rare disease. Cancer Treat Rev 2013; 39:584-91. [DOI: 10.1016/j.ctrv.2012.12.005] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2012] [Revised: 12/03/2012] [Accepted: 12/05/2012] [Indexed: 12/14/2022]
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FDG PET/CT in the Management of Primary Pleural Tumors and Pleural Metastases. AJR Am J Roentgenol 2013; 201:W215-26. [DOI: 10.2214/ajr.13.10572] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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44
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Second Italian Consensus Conference on Malignant Pleural Mesothelioma: State of the art and recommendations. Cancer Treat Rev 2013; 39:328-39. [DOI: 10.1016/j.ctrv.2012.11.004] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2012] [Revised: 11/08/2012] [Accepted: 11/13/2012] [Indexed: 10/27/2022]
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45
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Abstract
Pleural disease is now recognized as an important subspecialty of pulmonary medicine, with increasing provision being made for specialist services and procedures. In response, the field of pleural imaging has advanced in recent years, especially with regard to ultrasound. Salient multimodality imaging techniques are discussed.
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Affiliation(s)
- Chloe Mortensen
- Department of Radiology, Southmead Hospital, Bristol BS10 5NB, UK
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46
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Feigen M, Lee ST, Lawford C, Churcher K, Zupan E, Scott AM, Hamilton C. Establishing locoregional control of malignant pleural mesothelioma using high-dose radiotherapy and 18F-FDG PET/CT scan correlation. J Med Imaging Radiat Oncol 2011; 55:320-32. [DOI: 10.1111/j.1754-9485.2011.02274.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Gerbaudo VH, Katz SI, Nowak AK, Francis RJ. Multimodality Imaging Review of Malignant Pleural Mesothelioma Diagnosis and Staging. PET Clin 2011; 6:275-97. [PMID: 27156724 DOI: 10.1016/j.cpet.2011.04.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Early diagnosis and accurate disease staging in patients with malignant pleural mesothelioma (MPM) are essential in classifying such patients into prognostic subgroups to allow delivery of stage-specific therapies. This review addresses the current status of multimodality imaging in the diagnosis and staging of MPM. Clinical, research, and future directions in computed tomography (CT), magnetic resonance imaging, and PET/CT diagnosis and staging of MPM are discussed, including the use of novel PET probes. The article concludes with important take-home messages summarized as the pearls and pitfalls of each diagnostic modality in the diagnosis and staging of patients with MPM.
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Affiliation(s)
- Victor H Gerbaudo
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Harvard Medical School, Brigham & Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Sharyn I Katz
- Department of Radiology, Hospital of the University of Pennsylvania, University of Pennsylvania School of Medicine, 1 Silverstein Building, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Anna K Nowak
- Department of Medical Oncology, School of Medicine and Pharmacology, University of Western Australia, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands 6009, Western Australia, Australia
| | - Roslyn J Francis
- Department of Medical Oncology, School of Medicine and Pharmacology, University of Western Australia, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands 6009, Western Australia, Australia; Department of Molecular Imaging, School of Medicine and Pharmacology, University of Western Australia, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands 6009, Western Australia, Australia
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Murray LJ, Higham J, Suvarna SK, Craig GT, Bridgewater CH, Fisher PM, Thornhill MH. Oral presentation of malignant mesothelioma. ACTA ACUST UNITED AC 2011; 111:e21-6. [DOI: 10.1016/j.tripleo.2010.05.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2010] [Revised: 05/05/2010] [Accepted: 05/07/2010] [Indexed: 10/19/2022]
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Basu S, Saboury B, Torigian DA, Alavi A. Current Evidence Base of FDG-PET/CT Imaging in the Clinical Management of Malignant Pleural Mesothelioma: Emerging Significance of Image Segmentation and Global Disease Assessment. Mol Imaging Biol 2010; 13:801-11. [DOI: 10.1007/s11307-010-0426-6] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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50
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Diffusion-Weighted MRI of Malignant Pleural Mesothelioma: Preliminary Assessment of Apparent Diffusion Coefficient in Histologic Subtypes. AJR Am J Roentgenol 2010; 195:W125-30. [DOI: 10.2214/ajr.09.3519] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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