The Clinical, Pathological And Imaging Diagnosis In Malignant Pleural Mesothelioma

[Objectives] To investigate the clinical, pathological and imaging manifestation of MPM from the analysis of the large samples.[Material and Methods] To collect180cases confirmed as MPM by pathology from January1990to December2012, and analyze the epidemiological character and clinical symptoms, recording the number of those who had chest tightness, chest pain, shortness of breath, cough and expectoration and fever, respectively. Among these cases, the serological test was underwent in68cases, studying the four tumor makers of AFP, CEA, CA19-9and CA125respectively; the pleural effusion check was performed in50cases, evaluating the appearance, nucleated cell count, LDH, AFP, CEA, CA19-9and CA125respectively. Reviewing the pathological diagnosis reports of180cases with MPM, of which68cases had pathological type results, including epithelial, mixed and fibrosarcoma type; and67cases underwent immuno-histochemical examination, including the expression of MC, Vimentin and EMA. The imaging data of MPM were collected, including X-ray in113cases, B ultrasound in51, CT in136and MRI in8, analyzing the following imaging findings, pleural thickening, pleural effusion, mediastinal pleura thickening, interlobar fissure thickening, pulmonary metastasis, pericardium invasion, pleural calcification, lymphatic metastasis and destruction of ribs or centrum. The CT value of non-contrast, contrast and overlay among different types of pleural thickening were compared among24cases received CT enhanced scan. Contrast with CT primary diagnosis report, the imaging features of missed-mistaken diagnosis cases were analyzed. The differences of imaging findings were compared between Chuxiong and non-Chuxiong districts and among three pathological types.[Results]1. Among180cases with MPM, the ratio of male to female was1.6:1. The average age was (52.94+13.16) years old. Farmers accounted for up to122cases (67.78%). There were132cases (73.33%) in Chuxiong region, in which53cases (29.44%) in Dayao county accounted for the largest share;48cases (26.67%) in non-Chuxiong district, in which12cases (6.67%) in Kunming as the most.2. Among180cases, there were chest tightness in140cases, cough and expectoration112cases, shortness of breath in96cases, chest pain in82cases and fever in16cases.3. Among68cases underwent serum tumor markers detection, there were only1case (1.56%) with high AFP level in64cases;10cases (25.64%) with high CEA level in39cases;13cases (31.71%) with high CA19-9level in41cases; and19cases (45.24%) with high CA125level in42cases. The mean value of four tumor markers were all in the normal reference value range, according to the calculation of skewness distribution data.4. Among50cases underwent pleural effusion check, the appearance mostly presented as red (60%), opacity (98%) and clots (56%). The nucleated cell count of44cases was increased in23cases (52.27%). There were25cases (83.33%) with high LDH level among30cases.13cases (26%) were found malignant cells among50cases. The mean value of nuclear cell count and and LDH were higher than reference value. There were no cases with high AFP level among30cases;7cases (21.21%) with high CEA level among33cases;18cases (18.18%) with high CA19-9level among20cases. Only the mean value of CAl25was greater than the reference value.5.68cases were classified as three pathological types:epithelial(63.24%), sarcomatous (20.59%) and mixed types (16.18%). Among67cases underwent immunohistochemical examination, MC was expressed in53cases (88.33%) of60case; Vimentin in42cases (77.78%) of54cases; EMA in39cases (70.91%) of55cases. 6. From the evaluation of113cases with X-ray chest radiograph, the pleura thickening was found in42cases (37.17%). The pleural effusion mostly presented as unilateral (92cases,81.42%) and great quantity (55cases,48.67%). The detection of other imaging manifestations:mediastinal pleura thickening (3.54%), interlobar fissure thickening (6.19%), pleural calcification (2.65%), lung metastasis (15.93%) and bone destruction (6.19%) on X-ray chest radiography were not high.From51cases received B-ultrasound examination, pleural thickening was found in25cases (49.02%). The echo of pleural thickening mostly presented as strong (41.18%) and uneven (47.06%). The pleural effusion was found in49cases (96.08%), and most of unilateral (70.59%) and large (41.18%).From136cases with CT images, pleural thickening were detected in109cases (80.15%), the average thickness was (2.28±0.33) cm. The thickness of pleura was more than1cm in78cases (71.56%). The pleural thickening was mostly presented as diffuse (88cases,64.71%) and nodular (68cases,50.00%). The pleural effusion was given priority to unilateral (88.97%) and large (42.65%). The detection rates of mediastinal pleura thickening, interlobar fissure thickening, pleural calcification, pulmonary metastasis, cardiac metastasis and destruction of ribs or centrum were higher than X-ray chest radiograph. From24cases with CT contrast images, the CT value of pleural thickening for non-contrast, contrast and overlay were (30.25±3.44) HU,(47.62±4.68) HU and (17.37±2.37) HU respectively. There were no statistical differences among different range and types of pleural thickening. Among34cases (25.00%) failed to detect pleural thickening in initial diagnosis,27cases (19.85%) actually were not find thickening and the other7cases (5.15%) find pleural thickening in small nodular (<0.7cm) by reviewing.5cases (3.68%) were misdiagnosed, including central type lung cancer (2cases), invasive thymoma (1case), tuberculous pleurisy (1case) and pleural metastasis tumor(1case).From8cases with MRI images, the pleural thickening was found in8cases (100.00%), mostly of diffuse (6cases,75.00%) and nodular (5cases,62.50%). The pleural thickening was found as low signal on TWT1(62.50%) and high signal on TWT2(75.00%).8cases were found pleural effusion, with unilateral (100.00%) and large (50.00%). The mediastinum and interlobar fissure pleura thickening accounted for37.50%and50.00%respectively.7. There were no statistical differences (P>0.05) between Chuxiong (98cases) and non-Chuxiong (43cases) in imaging findings.8. To compare the imaging findings among43cases of epithelial,14cases of fibrosarcoma and11cases of mixed types, there were statistical differences in mediastinal pleura thickening (x2=12.547, P<12.547), interlobar fissure pleura thickening (x2=8.250, P<8.250) and lung metastasis (x2=8.486, P<0.05). The fibrosarcoma type was significantly higher than other two types, with10cases of mediastinal pleura thickening (71.43%),9cases of interlobar fissure pleura thickening (64.29%) and5cases of pulmonary metastasis (35.71%).[Conclusion]1. The most patients with MPM in this study are male and middle age. The farmers accounts for a large proportion. Dayao county in Chuxiong has the highest morbidity. There are not typical symptoms in clinical manifestations.2. AFP, CEA, CA19-9and CA125in some cases received serum tumor marker check are increased, but the mean values are in the reference range. Most of MPM patients with exudative pleural effusion, is rarely found malignant cells. For the detection of the tumor maker in pleural effusion, no cases is increased in AFP level, and only the mean value of CA125is higher than normal reference.3. The epithelial type accounts for a large proportion, and the number of fibrosarcoma and mixed types are quite. The expressions of MC, Vimentin and EMA are high from immunohistochemical examination.4. From the evaluation of X-ray, B-ultrasound, CT and MRI imaging, MPM is mainly characterized by pleural thickening and pleural effusion. The pleural thickening is mostly more than1cm, diffuse distribution and nodular appearance. The mediastinal pleura and interlobar fissure are often involved. Some cases display a series of signs of malignancy, such as lung metastasis, cardiac metastasis, mediastinal lymph node enlargement and destruction of bones. The calcification of pleural thickening is rare in this study. CT contrast scan show the slight enhancement for pleural thickening. There were no differences among the range and types of pleural thickening in CT mean value.5. CT findings without pleural thickening can not exclude MPM. The unapparent pleural thickening may lead to missed diagnosis. When mediastinal pleura thicken as mass, MPM should identified with central type lung cancer and thymic tumorcation. When the pleura thickening combined with lungs lesions should be identified with tuberculous pleurisy and pleural metastases.6. There were no differences between the patients with MPM in Chuxiong and non-Chuxiong regions in imaging findings.7. Comparison of three pathologic types in imaging findings, there were differences in mediastinal pleura thickening, interlobar fissure pleura thickening and lung metastasis. The fibrosarcoma type is more than other two types.