Malignant pleural mesothelioma

Case contributed by Dr Craig Hacking

Presentation

Worsening SOB

Patient Data

Age: 85
Gender: Female
Modality: X-ray

Extensive pleural thickening/fluid on the right laterally, which could represent an empyema or malignancy. Patchy consolidation in the right lower zone is likely within the middle and lower lobes. The left lung is clear. The heart is enlarged.

CT recommended.

Modality: CT

There is nodular pleural thickening in the right hemithorax, which encases the right lung, including extension onto the mediastinal pleura and into the fissures. The right lung demonstrates volume loss and there is mild deviation of the mediastinal structures toward the right side. Interlobular septal thickening is noted in the right lung, particularly at the lung base. No associated pleural effusion. The left pleural space are clear. No pulmonary nodule or mass lesion. Mosaic attenuation is demonstrated throughout both lungs. There are calcified pleural plaques in both hemithoraces.

Extensive pulmonary artery filling defects are demonstrated throughout both lungs in the lobar arteries (upper and lower lobes on both sides, and right middle lobe). The right ventricle is enlarged and there is straightening/leftward bowing of the interventricular septum. The right atrium is also dilated, which indicates an element of pre-existing right heart disease.

Several prominent mediastinal lymph nodes are demonstrated, including lower right paratracheal measuring 11 mm and subcarinal measuring 15 mm.

The imaged upper abdomen is unremarkable apart from a few tiny splenic calcifications. No suspicious bony lesions.

Conclusion

  • Pleural encasement of the right lung is representative of malignancy, which is likely mesothelioma given the presence of calcified pleural plaques indicating previous asbestos exposure but may be secondary (with typical primary sites including breast, lung or gastrointestinal tract).
  • Interlobular septal thickening in the right lung is suspicious for lymphangitis carcinomatosis.
  • Extensive bilateral pulmonary emboli, with CT features suggestive of right ventricular strain.

Case Discussion

Biopsy proven mesothelioma.

The patient's husband worked with asbestos.

The patient elected for conservative management given significant co-morbidities.

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Case Information

rID: 40143
Case created: 9th Oct 2015
Last edited: 18th Jan 2016
System: Chest
Inclusion in quiz mode: Included

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