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clinical and radiological findings in addition to a confirming tissue biopsy. A
review of the patient's medical history, including history of asbestos exposure is
taken, followed by a complete physical examination, x-rays of the chest or abdomen,
and lung function tests. A CT scan or MRI may also be done at this time. If any of
these preliminary tests prove suspicious for mesothelioma; a biopsy is necessary to
confirm this diagnosis.
Imaging Techniques and Their Value in Diagnosing and Assessing Mesothelioma
There are several imaging techniques which may prove useful when mesothelioma is
suspected due to the presence of pleural effusion combined with a history of
occupational or secondary asbestos exposure. While these imaging techniques can be
valuable in assessing the possibility of the cancer, definitive diagnosis is still
most often established through fluid diagnosis or tissue biopsy.
Some of the most commonly used imaging methods include:
? X-ray
A chest x-ray can reveal pleural effusion (fluid build-up) which is confined to
either the right (60%) or left (40%) lung. On occasion, a mass may be seen. Signs of
prior non-cancerous asbestos disease, such as pleural plaques or pleural
calcification, or scarring due to asbestosis may also be noted.
? Computed Tomography (CT)
CT scans are also able to define pleural effusion, as well as pleural
thickening, pleural calcification, thickening of interlobular fissures, or possible
chest wall invasion. CT, however, is not able to differentiate between changes
associated with benign asbestos disease (pleural disease), or differentiate between
adenocarcinoma of the lung which may have spread to the pleura verses mesothelioma.
CT scans may also be valuable in guiding
needle aspiration of pleural masses for tissue diagnosis.
? Magnetic Resonance Imaging (MRI)
MRI scans are most often used to determine the extent of tumor prior to
aggressive treatment. Because they provide images in multiple planes, they are
better able to identify tumors as opposed to normal structures. They are also more
accurate than CT scans in assessing enlargement of the mediastinal lymph nodes
(those lymph nodes which lie between the two lungs), as well as a clear
diaphragmatic surface, both of which play an important role in surgical candidacy.
? Positron Emission Tomography (PET)
PET imaging is now becoming an important part of the diagnosis and evaluation of
mesothelioma. While PET scans are more expensive than other types of imaging, and
are not always covered under insurance, they are now considered to be the most
diagnostic of tumor sites, as well as the most superior in determining the staging
of mesothelioma.
scans.
? CT/PET
For patients who may be candidates for aggressive multimodality treatment
(surgery, chemotherapy and radiation), accurate clinical staging is extremely
important. Integrated CT/PET imaging provides a relatively new tool in this respect,
and has become the imaging technique of choice for determining surgical eligibility.
By combining the benefits of CT and PET (anatomic and metabolic information) into a
single scan, this technology can more accurately determine the stage of the cancer,
and can help identify the best treatment option for the patient. Read about a
patients with malignant pleural mesothelioma.
A needle biopsy of the mass, or the removal and examination of the fluid surrounding
the lung, may be used for diagnosis, however, because these samples are sometimes
inadequate as far as determining cell type (epithelial, sarcomatous, or mixed) or
because of the unreliability of fluid diagnosis, open pleural biopsy may be
recommended. In a pleural biopsy procedure, a surgeon will make a small incision
through the chest wall and insert a thin, lighted tube called a thoracoscope into
the chest between two ribs. He will then remove a sample of tissue to be reviewed
under a microscope by a pathologist. In a peritoneal biopsy, the doctor makes a
small incision in the abdomen and inserts a peritoneoscope into the abdominal
cavity.
Once mesothelioma is suspected through imaging tests, it is confirmed by
pathological examination. Tissue is removed, put under the microscope, and a
pathologist makes a definitive diagnosis, and issues a pathology report. This is the
end of a process that usually begins with symptoms that send most people to the
doctor: a fluid build-up or pleural effusions, shortness of breath, pain in the
chest, or pain or swelling in the abdomen. The doctor may order an x-ray or CT scan
of the chest or abdomen. If further examination is warranted, the following tests
may be done:
* Video-Assisted Thoracoscopic Surgery (VATS)
Over the past decade, the use of video-assisted thoracic surgery (VATS) has become
one of the most widely used tools in the diagnosis of mesothelioma. Biopsies of the
pleural lining, nodules, masses and pleural fluid can now easily be obtained using
this minimally invasive procedure, and other therapies such as pleurodesis (talc)
for pleural effusions can be done concurrently.While the patient is under general
anesthesia, several small incisions or "ports" are made through the chest wall. The
surgeon then inserts a small camera, via a scope, into one incision, and other
surgical instruments used to retrieve tissue samples into the other incisions. By
looking at a video screen showing the camera images, the surgeon is able to complete
whatever procedures are necessary
In many cases, this video-assisted technique is able to replace thoracotomy, which
requires a much larger incision to gain access to the chest cavity, and because it
is minimally invasive, the patient most often has less post-operative pain and a
potentially shorter recovery period.
* Thoracoscopy
For pleural mesothelioma the doctor may look inside the chest cavity with a special
instrument called a thoracoscope. A cut will be made through the chest wall and the
thoracoscope will be put into the chest between two ribs. This test is usually done
in a hospital with a local anesthetic or painkiller.
If fluid has collected in your chest, your doctor may drain the fluid out of your
body by putting a needle into your chest and use gentle suction to remove the fluid.
This is called thoracentesis.
* Peritoneoscopy
For peritoneal mesothelioma the doctor may also look inside the abdomen with a
special tool called a peritoneoscope. The peritoneoscope is put into an opening made
in the abdomen. This test is usually done in the hospital under a local anesthetic.
If fluid has collected in your abdomen, your doctor may drain the fluid out of your
body by putting a needle into your abdomen and using gentle suction to remove the
fluid. This process is called paracentesis .
* Biopsy
If abnormal tissue is found, the doctor will need to cut out a small piece and have
it looked at under a microscope. This is usually done during the thoracoscopy or
peritoneoscopy, but can be done during surgery. .
Pathology and The Role of Pathologists in the Diagnostic Process
Pathology, or the scientific study of cells, tissue, or fluid taken from the body is
an integral part of a mesothelioma diagnosis. Most hospitals have their own
pathology labs staffed by board-certified pathologists and licensed technologists.
The importance of pathological diagnosis can not be underestimated, since the course
of treatment is dependent upon an accurate diagnosis.
To make a diagnosis, pathologists examine tissue under a microscope, and based on
established criteria, make a determination of benign vs. malignant cells.
Subsequently, the type of cancer is determined. Although most pathologists have a
general expertise of various diseases, a small number acquire training in a
subspecialty, such as mesothelioma. These are physicians who have received
world-wide recognition as premier experts, and have achieved high acclaim for their
research, published articles and abstracts, and teaching. For a list of expert
pathologists in the field of mesothelioma diagnosis, please call the MW toll free at
1-877-367-6376 or fill in the form at the bottom of this page specifying your
request.
Knowing the stage is a factor in helping the doctor form a treatment plan.
Mesothelioma is considered localized if the cancer is confined to the pleura, or
advanced if it has spread beyond the pleura to other parts of the body such as the
lungs, chest wall, abdominal cavity, or lymph nodes.
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