대한흉부영상의학회 Korean Society of Thoracic Radiology

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Weekly Chest CasesArchive of Old Cases

Case No : 335 Date 2004-03-27

  • Courtesy of Young-Jin Kim, M.D., Kyu Ok Choe, M.D. / Yonsei University Sinchon Severance Hospital, Seoul, Korea
  • Age/Sex 50 / F
  • Chief ComplaintRight pleuritic chest pain
  • Figure 1
  • Figure 2
  • Figure 3
  • Figure 4
  • Figure 5

Diagnosis With Brief Discussion

Diagnosis
Malignant mesothelioma, sarcomatous type
Radiologic Findings
Fig.1-2. CT shows fluid collection with pleural thickening and calcification at Rt. posterolateral costophrenic sulcus, suggesting old empyema change.

Fig. 3-5. CT obtained 2 months after initial CT shows further enlargement of empyema on the Rt. posterolateral costophrenic sulcus with bulging-out through intercostal space underneath serratus posterior muscle. Previously noted calcification is indefinite. Lung parenchyma seems to be infiltrated by the pleural lesion.



The patient had been underwent empyectomy and right lower lobectomy. On gross specimen, multiple well-demarcated solid nodules are seen, mainly involving the pleural surface and scattered within the lung parenchyma. Pathologic diagnosis was sarcomatous type malignant mesothelioma with involvement of attached ribs and lung parenchyma.
Brief Review
In the presence of pleural thickening, the most useful features for differentiation of malignancy in pleural diseases are the presence of a pleural rind, pleural nodularity, thickening greater than 1 cm, and mediastinal pleural involvement. Pleural calcification and subpleural soft tissue hypertrophy in fat tissue density is important CT finding for benign diseases.

Chronic empyema can cause a malignancy appearing some decades later and the majority of which are squamous cell carcinomas. Lymphoma, round-cell sarcoma, adenocarcinoma and malignant mesothelioma also have been reported. Radiologic findings suggesting the occurrence of malignancy are; increased radiopacity in the thoracic cavity, soft-tissue bulging and/or unsharpness of fat planes in the chest walls, destruction of bone near the empyema, and extensive medial deviation of the calcified pleurae. CT clearly delineated masses with soft-tissue attenuation.

Every radiologist should know this entity in observation of chest radiographs obtained in patients with chronic empyema, and further radiologic assessment and aggressive biopsy are recommended if malignancy is suspected.
References
1. Metintas M. et al. Computed tomography features in malignant pleural mesothelioma and other commonly seen pleural diseases. European Journal of Radiology 2002;41:1?9

2. Minami M. et al. Malignancy associated with chronic empyema: radiologic assessment. Radiology 1991;178(2):417-23

3. Hillerdal G. et al. Malignant mesothelioma secondary to chronic inflammation and old scars. Two new cases and review of the literature. Cancer 1985;55(9):1968-72.

4. Smith R. et al. Pleural mesothelioma presenting initially as empyema. Diagnostic Cytopatholog 2003;29:119-121
Keywords
Pleura, Malignant tumor,

No. of Applicants : 30

▶ Correct Answer : 12/30,  40.0%
  • - Air force education & training command Hospital, Korea Hyukwon Chang
  • - Escola Paulista de Medicina, Brasil Jose LM Almeida Prado
  • - Hangang SacredHeart Hospital, Korea Eil Seong Lee
  • - Hanyang University Hospital, Seoul, Korea Yo Won Choi
  • - Hanyang University Hospital, Seoul, Korea Mi Jeong Jang
  • - Incheon Sarang Hospital, Korea Jung Hee Kim
  • - Mallinckrodt Institute of Radiology, USA Jin Mo Goo
  • - National Taiwan University Hospital, Taiwan Tan Che Kim
  • - Nowon Eulji hospital, Korea Jeong Joo Woo
  • - Ondokuz Mayis University, Samsun, Turkey Cetin Celenk
  • - Seoul veterans hospital, Korea Seo-Hyun Kwak
  • - Social Security Hospital, Ankara, Turkey Meric Tuzun
▶ Semi-Correct Answer : 8/30,  26.7%
  • - Annecy Hospital, France Gilles Genin
  • - CH Lyon sud, France Xavier Riviere
  • - CHU Nancy-Brabois, France Denis Regent
  • - CIM Saint Dizier, France JC Leclerc
  • - Homs National Hospital, Homs, Syria Rami Abou Zalaf
  • - Ohio State University Med Cntr, Ohio, USA Sumit Seth
  • - Samsung Medical Center, Korea Sung Shine Shim
  • - Sharma Clinic, Jaipur, India Dinesh Sharma
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