Malignant pleural mesothelioma presenting as perifissural nodules

Case contributed by Ahmed Mohamed Ali Aboughali

Presentation

The patient presented complaining of weight loss and past history of smoking. An x-ray study of the chest revealed shadow in the right upper lobe. The possibility of lung cancer was raised and subsequent CT study of the abdomen and pelvis was requested.

Patient Data

Age: 75 years
Gender: Female

Axial images show multiple bilateral variable-sized nodular opacities.

Coronal and sagittal reformated images confirm its location along the interlobar fissures.

The mediastinal window images show enlarged right hilar lymph nodes along with the peri-fissural nodular opacities. 

The patient proceeded to CT guided percutaneous lung biopsy, which revealed malignant mesothelioma - epitheloid variant.

Case Discussion

CT is the primary imaging modality used for the evaluation of malignant pleural mesothelioma. Key CT findings that suggest MPM include unilateral pleural effusion, nodular pleural thickening and interlobar fissure thickening. Growth typically leads to tumoral encasement of the lung with a rind-like appearance.

Calcified pleural plaques are found at CT in approximately 20% of patients. There is also frequent contraction of the affected hemithorax with associated ipsilateral mediastinal shift, narrowed intercostal spaces, and elevation of the ipsilateral hemidiaphragm. Sometimes, MPM appears as nodular thickening of the interlobar fissures giving the appearance that may be mistaken as intrapulmonary nodules on axial images. 

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