Tina Mosaferi, Harvard Medical School Year III Gillian Lieberman, MD

Transcription

1 July 2014 Tina Mosaferi, Harvard Medical School Year III

2 1. Our Patient-Introduction 2. Asbestos Basics 3. Pulmonary Findings Manifestations demonstrated by companion patients 4. Our patient-conclusion 2

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4 83 M CC: SOB on exertion HPI: Family noticed SOB upon exertion. Patient subsequently reported sharp left chest pain and right chest pressure for unspecified period of time. Hoarsened voice. No cough, fevers, or chills. 4

5 PMH: Hay Fever, cholecystectomy, DM, tonsillectomy, TURP, bilateral carpal tunnel SH: Widower, 13 children. Smoking: Quit 25 years ago; 100 pack year hx. Alcohol: Drinks 1-2 beverages/day. Employment: Construction and carpentry (hardwood floor installation) asbestos exposure. 5

6 Relevant PE*: Vitals: BP 109/69, HR 86, Temp 97.2, RR 16, O2 Sat 96% RA. Car: RRR; no murmurs, rubs, or gallops. Pulm: Diminished breath sounds on right, clear on left. Ext: No LE edema. *patient s initial presentation was at an OSH; noted PE findings from follow-up at BIDMC 6

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8 ACR Appropriateness Criteria Chief Complaint Recommendation Dyspnea-Cardiac origin Dyspnea-Pulm origin Chronic chest pain-low CAD risk X-ray chest + Resting ECHO X-ray chest X-ray chest 8

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10 FRONTAL CHEST X-RAY Courtesy of Paul Spirn, MD. PACS, BIDMC. 10

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12 Greek meaning: inextinguishable Definition: group of magnesium silicate minerals that tend to separate into fibers Fibers are resistant to heat and acid 2 major groups: Serpentine Chrysotile (white asbestos) Amphiboles Amosite (brown asbestos) Crocidolite (blue asbestos) Tremolite 0&q=

13 Not combustible, great tensile strength, and durable insulation materials, brake pads and linings, floor tiles, electric wiring, paints, and cements. Individuals at risk: Mining and milling Industrial applications Non-occupational exposure 13

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15 1. Our Patient-Introduction An 83yo male presenting with SOB on exertion. Occupational asbestos exposure noted in social history. Diminished right breath sounds noted on exam. Right pleural effusion identified on chest radiograph. 2. Asbestos Basics Asbestos: a group of magnesium silicate minerals that separate into fibers. Resistant to heat and acid, it has been used in many industries. Complex pathogenesis depends on type of asbestos exposure, duration of exposure, and final localization of inhaled fibers. 15

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17 Spectrum of Pulmonary Manifestations Pleural Diseases Interstitial Lung Diseases Malignant Diseases Benign Pleural Effusions Asbestosis Lung Cancer Pleural Plaques Mesothelioma Diffuse Pleural Thickening This diagram will be used to guide us through our discussion. 17

18 Spectrum of Pulmonary Manifestations Pleural Diseases Interstitial Lung Diseases Malignant Diseases Benign Pleural Effusions Asbestosis Lung Cancer Pleural Plaques Mesothelioma Diffuse Pleural Thickening 18

19 Benign Pleural Effusions Most common abnormality within the first 20 years. Latency - 1 to 58 years. Occurs in ~3% of asbestos-exposed individuals. Unilateral>bilateral. May resolve spontaneously, persist for months, recur. Often leave area of pleural thickening. Distinguish from malignant effusion! 19

20 AXIAL C- CHEST CT Müller, N. and Silva, C. Imaging of the Chest: Expert Radiology Series. 20

21 Pleural Plaques Most common manifestation of asbestos exposure. Circumscribed, focal areas of parietal pleural thickening. Bilateral and asymmetric. Latency-20 to 30 years. 10%-15% are calcified. Do not undergo malignant change; generally cause no symptoms. 21

22 Bilateral, asymmetric, calcified pleural plaques CORONAL C- CHEST CT. Courtesy of George Watts, MD. PACS, BIDMC. 22

23 Diffuse Pleural Thickening Occurs in 9% to 22% of asbestos-exposed individuals. Latency- 10 to 40 years. Smooth, uninterrupted visceral pleural density extending over at least a fourth of the chest wall. Bilateral>Unilateral. Mediastinal border generally unaffected. Restrictive pulmonary effect. 23

24 AXIAL C+ CHEST CT. Courtesy of Paul Spirn, MD. PACS, BIDMC. CORONAL C+ CHEST CT. Courtesy of Paul Spirn, MD. PACS, BIDMC. -Calcified pleural plaque -Diffuse pleural thickening 24

25 Spectrum of Pulmonary Manifestations Pleural Diseases Interstitial Lung Diseases Malignant Diseases Benign Pleural Effusions Asbestosis Lung Cancer Pleural Plaques Mesothelioma Diffuse Pleural Thickening 25

26 Asbestosis Slowly progressive, diffuse pulmonary fibrosis. Latency- 20 to 40 years. Intralobular linear opacities (reticular pattern). Subpleural small rounded or branching opacities. Mainly peripheral and dorsal regions of the lung bases. Associated with significant exposure. 26

27 Subpleural reticulation Intralobular linear opacities AXIAL C+ CHEST CT. Currie, G. et al. BMJ 2009;339:b

28 Spectrum of Pulmonary Manifestations Pleural Diseases Interstitial Lung Diseases Malignant Diseases Benign Pleural Effusions Asbestosis Lung Cancer Pleural Plaques Mesothelioma Diffuse Pleural Thickening 28

29 Mesothelioma Unilateral sheet-like or lobulated pleural thickening. Thickening of the mediastinal pleura. Unilateral pleural effusion. Ipsilateral volume loss in approximately 40% of cases. Latency- 25 to 60 years. 29

30 Mesothelioma in right pleural space encasing the right lung Possible invasion of mediastinal structures AXIAL C- CHEST CT. Courtesy of Paul Spirn, MD. PACS, BIDMC. 30

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32 Thoracentesis Results: Suspicious, highly atypical mesothelial cells appearing in groups and complex clusters. Interim: recurrent pleural effusions. Video-assisted thoracoscopic surgery: right pleural biopsy. Diagnosis: Mesothelioma 32

33 Mesothelioma in right pleural space CORONAL C+ CHEST CT. Courtesy of Paul Spirn, MD. PACS, BIDMC. 33

34 Median survival of mesothelioma patients: Approximately months from diagnosis. Fighting the odds with the love of his children and the support of his healthcare providers, our patient survived for 3 years following his diagnosis. 34

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36 1. Our Patient- Introduction 83M SOB on exertion Recurrent pleural effusions Biopsy-confirmed mesothelioma 2. Asbestos Basics Magnesium silicate minerals Exposure Pathogenesis 4. Pulmonary Manifestations Pleural Diseases Benign Pleural Effusions Pleural Plaques Diffuse Pleural Thickening Interstitial Lung Diseases Asbestosis Malignant Diseases Lung Cancer Mesothelioma 5. Our Patient-Outcome Mesothelioma Poor Prognosis 36

37 American College of Radiology < American Thoracic Society. Diagnosis and initial management of nonmalignant diseases related to asbestos. American Journal of Respiratory and Critical Care Medicine 2004; 170. Currie GP, Watt SJ, Maskell NA. An overview of how asbestos exposure affects the lung. BMJ 2009;339:b3209. Muller NL, Silva CIS. Imaging of the chest: Chapter 78 Asbestos-Related Diseases. Saunders, 2008: UpToDate < 37

38 Asbestos - New Zealand guidelines for the management and removal of asbestos (3rd Edition). New Zealand Demolition and Asbestos Association, March < Currie GP, Watt SJ, Maskell NA. An overview of how asbestos exposure affects the lung. BMJ 2009;339:b3209. Muller NL, Silva CIS. Imaging of the chest: Chapter 78 Asbestos-Related Diseases. Saunders, 2008: What is asbestos? State of Connecticut: Department of Public Health. Feb < 38

39 Dr. Neda Sedora-Roman, for thoughtfully following up on my many s and questions. Dr. Paul Spirn, for taking the time to provide me with a wealth of interesting cases and images. Dr. Gillian Lieberman, for her dedication in building a truly phenomenal course. My amazing classmates, for making me smile and laugh each and every day. 39