Diagnosis of pleural mesothelioma
Standard chest X-ray in two projections
Tc chest with or without contrast medium
Tc abdomen without and with contrast
VATS with talcaggio
Tc-PET with 18FDG
Definition histological morphology - study receptor EGFR - IGFR - VEGFR - PDGFR - CD117
Treatment of pleural mesothelioma
Surgery for pleural mesothelioma in stage I is the main option - the talcaggio with thoracic radiotherapy on the breaches - hyperthermic perfusion chemotherapy in the course of surgery, systemic therapy is performed with the use of targeted agents on the basis of study tissue, with or without associated chemotherapy administered with metronomic technique.
What is Pleural Mesothelioma
The mesoteli but are not limited to the pleura are fibrous membranes which are also the heart (pericardium), the intestine (peritoneum) and testicles (tunica vaginalis).
Primary tumors at the level of mesoteli are quite rare, and are a frequent site colonization of metastatic tumors from other locations. As the primary tumor are benign (very rare) and malignant forms, among them the most frequent is the following pleural mesothelioma peritoneal mesothelioma.
The pleural mesothelioma in the world has an impact on the population was 2.2 cases per million population. The distribution of the incidence in Italy is not the same as the frequency between the two sexes. The most affected age is between 40 and 60 years old and the male is affected in 70% of cases. This data is correlated with greater occupational exposure of men to carcinogens such as asbestos. And 'one of the cancers for which it is determined the order causative relationship with exposure to asbestos.
workers engaged in the manufacture, extraction, separation, handling, carding, spinning and weaving, as well as mineral in particular those of the shipyards in the coibentisti, it was demonstrated in epidemiological work, that the mesothelioma mortality was 7% of the total causes of death.
All the substances from which we extract the asbestos such as cryolite, the chrysotile, amosite, and others may be the cause of mesothelioma.
What is asbestos?
Asbestos is a silicate of magnesium with more or less small amount of iron and calcium. It is a mineral with finely fibrous structure. Sometimes it comes from the decomposition of certain amphiboles which are a family of silicate mineral very abundant in nature, composition quite varied and complex.Minerals are of prismatic shape, belonging to the rhombic or monoclinic crystal systems, considerable hardness and density, vitreous luster and color varying from white to black.
The amphiboles have an interest especially from the scientific point of view.Members of the family are particularly important for the study of mineralogy - petrographic are orneblende (containing magnesium, aluminum and iron), the sodic amphiboles (such as glaucophane and riebechite) and minerals of the isomorphous series tremolite - actinolite, is most often considered a variety of serpentine which is a product of transformation of pyroxene and / or olivine for serpentinization of peridotite. There are three forms in which it occurs in nature, lizardite, antigorite and chrysotile in fibrous aggregates (asbestos). It has a white or silvery gray sometimes greenish or brownish.Depending on the length of the fiber we asbestos long fiber, short fiber and for cartons.
Outside of reactive processes is not known as asbestos causes mesothelioma. Since it is absorbent fibers is likely that catalyze biochemical reactions with the production of a substance or oncogenic become carriers of substances with these characteristics.
Another hypothesis and that the sub-microscopic fibrils are phagocytized by mesothelial cells, which possess this activity, in these cells by inducing a reaction that leads over time to a stable mutation cancerous. This is so true that the time interval from exposure to asbestos on the occurrence of the disease on average spend 20 to 30 years.
Classification of pleural mesothelioma
The malignant primary tumors of the serous membranes are localized in 60% -70% in the pleura, the peritoneum in 30% -35%, 2% in the pericardium and sporadically in the tunica vaginalis testis.
Microscopic evaluation identifies various forms: papillary or tubular 45% -50% pure epithelial, mesenchymal or sarcomatous 25% pure and biphasic or mixed 15% -20%.
macroscopic evaluation involves four stages (Butchart classification): Stage I: disease confined to one hemithorax - Stage II disease invades the chest wall or the mediastinum - stage III disease that affects the peritoneum infiltrating the diaphragm and the pericardium with extrathoracic lymph node involvement and the contralateral pleura - Stage IV disease with the presence of distant metastases
Diagnosis and Symptoms of pleural mesothelioma
The pleural mesothelioma in 70% of cases are diagnosed late. Thesymptoms of pleural mesothelioma , which are present for some time and are underestimated, are chest pain, shortness of breath and coughing.More belatedly appears asthenia, anorexia, weight loss and fever.Peritoneal mesothelioma presents with abdominal pain and ascites, pericardial localization is manifested by dyspnea and pleural blood-serum to pericardiocentesis, location in the tunica vaginalis testis presents with unilateral hydrocele also with liquid blood serum. Pleural mesothelioma is the most common form of cancer of the mesothelial tissue pathology, but beyond the diagnostic procedures and treatments pseudo-surgical and surgical, pharmacological therapeutic approach is similar.
pleural mesothelioma in the clinical examination reveals a pleural effusion in 80% of cases.
tests are instrumental chest radiography and chest Tc standard or multi-layer with or without contrast medium. The useful addition to the therapeutic thoracentesis allows you to sample liquid in which to practice cytology. The Tc-guided needle biopsy or eco-giudata allows a more adequate sampling of tissue for histological determination. Thoracoscopy over the biopsy for a better diagnostic definition, it also allows therapeutic treatments (talcaggio). Bronchoscopy allows viewing of the bronchial tree and a trans-bronchial biopsy, this technique is rarely practiced. MRI of the chest with contrast medium results in terms of diagnostic reliability similar to Tc multilayer. The Tc-PET allows a more sensitive given morpho-functional. Therapy There are no clear guidelines for the treatment ofmesothelioma . This fact is linked on the one hand by the limited number of cases, the other by a more ominous prognosis. therapy however is closely dependent on the stage. For the stado selected cases of stage I and II and III are the main option in the surgery. surgery makes use of pleurectomy with decortication or extrapleural pleuropneumonectomia which must always follow a chemioradioterapica adjuvant therapy for the high percentage of disease relapse after radical surgery also R0, which stood at 70% of the cases. Have been practiced treatments integrated with intraoperative perfusion ipertermiàca chemotherapy with therapeutic impact of modest significance. surgery also uses the talcaggio, a technique that is practiced in pleuroscopy through the pleuroscope is removed and the liquid is introduced talc that creating a local inflammatory reaction is to join the two pleural layers preventing the reform of the payment that significantly reduces the performance status of the patient. In this technique must follow a thoracoscopy radiotherapy in the gap to limit or avoid a potential seeding of tumor cells that cause the formation of subcutaneous nodules that create various problems in the course of the disease. Thechemotherapy is considered the treatment of choice in cases with inoperable technique radical or after talcaggio. This uses as a standard of platinum and its derivatives combined with a second drug that can be pemetrexed, gemcitabine or paclitaxel with or without radiation therapy.deserves some mention in the most Alimta (pemetrexed), a new antimetabolite that belongs to the category of antifolates by interfering with the synthesis of purine and pyrimidine. Differently from the other molecules of the same family that has a multi-target enzyme action, it acts on the thymidylate synthase (TS) on the dihydrofolate reductase (DHFR), and glycinamide ribonucleotide formiltransferasi (GARFT). This makes a molecule with greater potential than the other.
In my opinion that is in this case a therapeutic approach with multiple medications to impact receptor, previous immunohistochemical study and, if possible, of the gene profile. These drugs or not associated with a metronomic chemotherapy taken with technique should be prescribed according to an algorithm that takes into account the biology of this cancerous tissue that has a small share differentiated cancerous cell from which the substantial chemoresistance which is evident in the clinic. We have to act, as far as possible, on the CT scan cells over-expressing the receptors identified in the immunohistochemical study (partly receptors expressed by the cells also differentiated cancer) and cancer stem as known at the time (ie the domain of the EGFR receptor Wnt-sensitive gefitinib) or with drugs pro-differentiating.
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