University of Maryland Medical Center, Baltimore, MD
Copyright 2016, American College of Chest Physicians. All Rights Reserved.
SESSION TITLE: Fellow Case Report Slide: Disorders of the Pleura
SESSION TYPE: Affiliate Case Report Slide
PRESENTED ON: Sunday, October 23, 2016 at 03:15 PM - 04:15 PM
INTRODUCTION: Malignant pleural mesothelioma (MPM) is a rare disease with an annual incidence of 3000 cases in the U.S. Up to 80% of MPM are related to asbestos exposure. PET has shown to be accurate in distinguishing malignant vs benign pleural disease .
CASE PRESENTATION: 63-year-old male veteran with 70-pack-year smoking history presented with complaints 15-lb weight loss and cough. He had worked as a plumber for 40 years with ongoing asbestos exposure. Exam notable for normal vital signs, temporal wasting and distant breath sounds without wheezes or rales. Chest CT showed emphysema and right middle lobe volume loss with loculated, lobular-appearing pleural effusion. PET/CT did not show any abnormal FDG uptake in the right pleura or remainder of the chest. He underwent VATS with pleural drainage, biopsy and extensive decortication. Pathology revealed epithelioid type malignant mesothelioma involving parietal and visceral pleura with clear margins (stage pT1bN0). Postoperatively, he was started on adjuvant chemotherapy with cisplatin and pemetrexed.
DISCUSSION: This patient had clinical history and radiographic findings concerning for mesothelioma, despite lack of pleural FDG uptake. He was found to have biopsy-proven Stage I MPM. Several studies have demonstrated the accuracy of PET/CT in detecting pleural malignancy. In 83 patients with pleural lesions, PET-CT had 100% sensitivity and 94.8% specificity in detecting malignancy (max SUV greater than 3) with no false negatives. A 2009 study of 31 patients with pleural disease showed that PET/CT correctly identified 15 of 17 cases of MPM, with two false negatives.
CONCLUSIONS: While PET imaging has been shown to be accurate in distinguishing benign from malignant pleural disease, the clinical context should always be taken into account when one piece does not fit the puzzle.
Reference #1: Truong MT, Viswanathan C, Godoy MB, Carter BW, Marom EM. Malignant pleural mesothelioma: role of CT, MRI, and PET/CT in staging evaluation and treatment considerations. Semin Roentgenol. 2013;48:323-34
Reference #2: Schneider DB, Clary-Macy C, Challa S, et al. Positron emission tomography with F18-fluorodeoxyglucose in the staging and preoperative evaluation of malignant pleural mesothelioma. J Thorac Cardiovasc Surg. 2000;120:128-33.
Reference #3: Yildirim H, Metintas M, Entok E, et al. Clinical value of fluorodeoxyglucose-positron emission tomography/computed tomography in differentiation of malignant mesothelioma from asbestos-related benign pleural disease: An observational pilot study. J Thorac Oncol, 2009;4: 1480-84.
DISCLOSURE: The following authors have nothing to disclose: Stephanie Wappel, Janaki Deepak
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