Ga Ush Di Ambil Statiskinya p4

576 radiology.rsna.
org
n
Johan Coolen, MD Frederik De Keyzer, MSc Philippe Nafteux, MD Walter De Wever, MD, PhD Christophe Dooms,
MD, PhD Johan Vansteenkiste, MD, PhD Aurélie Derweduwen, MD Ilse Roebben, MSc Eric Verbeken, MD, PhD
Paul De Leyn, MD, PhD Dirk Van Raemdonck, MD, PhD Kristiaan Nackaerts, MD, PhD Steven Dymarkowski, MD,
PhD Johny Verschakelen, MD, PhD
1 From the Departments of Radiology (J.C., F.D.K., W.D.W., I.R., S.D., J. Verschakelen), Thoracic Surgery (P.N.,
P.D.L., D.V.R.), Pneumology (C.D., J. Vansteenkiste, A.D., K.N.), and Pathology (E.V.), University Hospitals Leuven,
Herestraat 49, B-3000 Leuven, Belgium. Received September 16, 2013; revision requested November 20; final
revision received May 16, 2014; accepted June 26; final version accepted July 18. Address correspondence to J.C.
(e-mail: Johan. Coolen@uzleuven.be).
q RSNA, 2014
Note: This copy is for your personal non-commercial use only. To order presentation-ready copies for distribution to your
colleagues or clients, contact us at www.rsna.org/rsnarights.
Malignant Pleural Mesothelioma: Visual

Assessment by Using Pleural Pointillism
at Diffusion-weighted MR Imaging1
Purpose: To evaluate the diagnostic accuracy of the visual assessment of malignant pleural mesothelioma (MPM) on magnetic
resonance (MR) images by using two known visual markers (mediastinal pleural thickness and shrinking of the lung) and a newly
introduced one (pleural pointillism).
Materials and Methods:
With the approval of the local ethics committee, 100 consecutive patients (mean age, 61.4 years; age range, 18–87 years; 75 men,
25 women) suspected of having MPM pleural abnormalities underwent positron emission tomography/computed tomography and
MR imaging, including diffusion-weighted (DW) MR imaging, followed by explorative thoracoscopy or guided biopsy with
histopathologic confirmation. Because visual assessment is still the preferred method of image interpretation, the diagnostic
accuracy of mediastinal pleural thickening, shrinking lung (hemithorax volume decrease due to fibrosis), and pleural pointillism
were examined. Pleural pointillism was denot- ed by the presence of multiple, hyperintense pleural spots on high-b-value DW
images. Histopathologic findings in the surgical specimen served as the reference standard. McNemar tests with Bonferroni
correction were used to assess differences in accuracy among the three examined markers.
Results: Of 100 patients, 33 had benign pleural alterations, and 67 had malignant pleural diseases (MPDs); 57 of 67 had MPM. A
total of 78 patients received a correct diagnosis (benign vs malignant) on the basis of mediastinal pleural thickening (sensitivity,
81%; specificity, 73%; accuracy, 78%); and 66 patients, on the basis of shrinking lung (sensitivity, 60%; specificity, 79%;
accuracy, 66%). The correct diagnosis was indicated on the basis of pleural pointillism in 88 patients (sensitivity, 93%;
specificity, 79%; accuracy, 88%).
Conclusion: Visual assessment of pleural pointillism on high-b-value DW images is useful to differentiate MPD from benign
alterations, performing substantially better than mediastinal pleural thickness and shrinking lung, and might obviate
unnecessary invasive procedures for MPM.
q RSNA, 2014
Radiology: Volume 274: Number 2—February 2015
THORACIC IMAGING: Malignant Pleural Mesothelioma MR Visual Assessment Coolen et al
M
alignant (MPM) of the pleura is pleural an uncommon that mesothelioma can present tumor
a diagnostic challenge. Currently, the definitive diagnosis of MPM always is based on the results obtained from an adequate
biopsy sample in the context of appropriate clinical, radiologic, and surgical findings (1).
Computed tomography (CT) has been used widely as the primary imaging modality for evaluation of MPM (2–6). Although
there are no pathogno- monic features, circumferential pleural thickening with or without pleural effusion, nodular pleural
thickening, involvement of the interlobar fissures, mediastinal pleural involvement, contraction of the pleura, and mediastinal
lymph node invasion (6,7) are considered strongly suggestive of malignant pleural disease (MPD). Whereas the positive
predictive value (PPV) of these features is high, their absence does not exclude diagnosis of MPM. Sensitiv- ity varies between
38% and 70%; and specificity, between 64% and 100% (2). At present, integrated fluorine 18 fluorodeoxyglucose (FDG) posi-
tron emission tomography (PET)/CT
n
is considered the standard technique
the lung) and a newly introduced one for staging MPM (8,9) because it com-
(pleural pointillism) bines metabolic and anatomic information (9). Several
authors (4,10–13) evaluated pleural disease that was sus-
Materials and Methods
pected of being MPM by using FDG PET with visual analysis and reached
Subjects a sensitivity of 92%, with a specific-
This prospective study was approved by ity of 75% and an accuracy of 89%.
the local ethics committee of University However, FDG PET is not completely
Hospitals Leuven (Leuven, Belgium), tumor specific, and tracer uptake can
and written informed consent was ob- be seen in benign inflammatory lesions
tained from all patients. Between No- or talc pleurodesis as well, occasion-
vember 2009 and December 2012, we ally making accurate staging of MPM
included 109 consecutive patients who difficult (14).
had pleural disease and were suspect- Although magnetic resonance (MR)
ed of having MPM; all were scheduled imaging is not used widely for these ap-
for histopathologic examination within plications, it has advantages over FDG
the first weeks after CT and MR imag- PET/CT because of the excellent soft-
ing. Nine patients were excluded for tissue contrast and the absence of ioniz-
the following reasons: three patients ing radiation (15). Moreover, functional
refused to sign the informed consent MR imaging techniques such as diffu-
form, two patients had claustropho- sion-weighted (DW) MR imaging and
bia, two patients had a pacemaker, one dynamic contrast material–enhanced
patient wore a nerve stimulator, and MR imaging already have proved their
one patient was unable to be placed worth in the differentiation of malig-
in the dorsal decubitus position be- nant from benign pleural disease and in
cause of pain. The remaining 100 pa- the assessment of chest wall and dia-
tients (mean age, 61.4 years; range, phragmatic involvement (16–20).
18–87 years; 25 women [mean age, Especially relatively late in disease
58.4 years; range, 32–79 years] and progression, when pleural lesions are
Advances in Knowledge
overt, differentiation between normal n Visual evaluation of pleural pointillism,
consisting of multiple, hyperintense pleural spots on high-b-value diffusion-weighted (DW) MR images, enables differentiation
between benign and malignant pleural lesions with a sensitivity of 93% (62 of 67) and a specificity of 79% (26 of 33). n
Malignant pleural disease is likely to be present if the thickened unilateral pleura manifests as pleural pointillism on high-b- value
DW MR images (positive predictive value, 90% [62 of
tissue and malignant thoracic cage invasion becomes crucial to distinguish between patients who are most likely to benefit from
an aggressive multimodality regimen and those who would benefit from systemic treatment before performance status
decreases. In these situations, CT tends to lead to underestimation of early chest wall invasion (21). In this prospective study,
we aimed to evaluate the diagnostic accuracy of the visual assessment of MPM at MR imaging by using two known visual
markers (mediastinal pleural thickness and shrinking of
69]). n The diagnostic accuracy of pleu-
ral pointillism (88% [88 of 100]) is substantially better than that of mediastinal pleural thickness (78% [78 of 100], P = .23) and
of shrinking lung (66% [66 of 100], P , .001).
Published online before print 10.1148/radiol.14132111 Content codes:
Radiology 2015; 274:576–584
Abbreviations: DW = diffusion weighted FDG = fluorine 18 fluorodeoxyglucose H-E = hematoxylin-eosin MPD =
malignant pleural disease MPM = malignant pleural mesothelioma NPV = negative predictive value PPV = positive
predictive value
Author contributions: Guarantors of integrity of entire study, J.C., C.D., E.V., K.N., J. Verschakelen; study
concepts/study design or data acquisition or data analysis/interpretation, all authors; manuscript drafting or
manuscript revision for important Implication for Patient Care
intellectual content, all authors; approval of final version of
n Visual assessment of pleural
submitted manuscript, all authors; literature research, J.C., W.D.W., E.V., J. Verschakelen; clinical studies, J.C.,
F.D.K., pointillism could allow accurate
P.N., W.D.W., J. Vansteenkiste, A.D., I.R., E.V., P.D.L., D.V.R., diagnosis of
malignant pleural
K.N., S.D.; statistical analysis, J.C., F.D.K., P.N., W.D.W.; mesothelioma and
could help in selection of an appropriate
and manuscript editing, J.C., F.D.K., P.N., W.D.W., C.D., J. Vansteenkiste, E.V., P.D.L., K.N., S.D., J. Verschakelen
biopsy location.
Conflicts of interest are listed at the end of this article.
radiology.rsna.org 577
Figure 1
578 radiology.rsna.org
n
Figure 1: Data obtained in a 69-year-old man with low back pain. A, B, CT images used to guide biopsy of a
tumor-involved right diaphragmatic crus (arrow on A); biopsy results indicated an epithelioid MPM (not shown), but
pleuroscopic examination results could not be used to confirm this diagnosis initially. E, F, I, J, Additional PET/CT
images show an FDG-avid lesion in the right diaphragmatic crus (arrow on I, J), and the pleural activity (arrow on E,
F) on the right was interpreted as postop- erative pleuritis. C, D, DW images show the diaphragmatic lesion
(arrowhead on D) and two hyperintense pleural spots (arrows on C). These anatomic lesions (arrows on G,
arrowhead on H) were confirmed at thoracotomy. All images were obtained in the axial plane. K, L, Histopathologic
specimen of the pleural lesion shows a tumoral pleural node at hematoxylin-eosin (H-E) staining (K) and is positive at
additional immunohistochemical calretinin staining (L). (Original magnification, 312.5.)
75 men [mean age, 62.4 years; range, 18–87 years]) were scheduled for MR imaging within 24 hours before the invasive
diagnostic procedure. Of these 100 patients, 69 (69%) were assigned to a therapy planning program for pleural disease,
including additional PET/ CT within 24 hours before the invasive diagnostic procedure, which was thoracotomy for 39 (39%)
(Fig 1) and video- assisted thoracic surgery with biopsy for 30 (30%). In the other 31 patients (31%), pleural tissue sampling
occurred during pleuroscopy (24 patients) (Fig 2) or with transthoracic core biopsy punc- ture with CT guidance (seven patients)
(Fig 3). Diagnostic CT was performed an average of 7 days (range, 0–14 days) before MR imaging.
Thoracic Imaging CT images were obtained by using multidetector CT scanners (Somatom Sensation 64 or 16 or Volume Zoom;
Siemens Healthcare, Erlangen, Ger- many). The examinations were performed at inspiration after intravenous administration
of 1.5 mL of iobitridol (Xenetix 350; Guerbet, Roissy, France) per kilogram of body weight at the rate of 2.5 mL/sec with a
power injector (Dual Shot Alpha; Nemoto Kyorindo, Tokyo, Japan), ex- tending from the lung apices to the costodiaphragmatic
sulci. Technical parameters of the scanning protocol included 120 kVp, 120–250 mAs (automatic dose modulation), pitch of 1.2
mm, and collimation of 0.75–1.5
mm, from which 3-mm-thick axial and coronal images (in-plane resolution, 0.7 3 0.7 mm) were reconstructed.
PET/CT was performed on an integrated PET/CT scanner (Biograph TruePoint V; Siemens Healthcare) including a
40-section CT scanner. Patients received an intravenous in- jection of FDG, which was produced in-house, and then rested for 60
minutes before imaging. The activity was based on weight according to the following formula: A = (W · 4) + 20, where A is
activity in megabec- querels and W is weight in kilograms. The standard interval between injec- tion and scanning was 75
minutes. Contrast-enhanced CT and emission PET acquisitions were obtained in the
Figure 2
Figure 2: Data obtained in a 76-year-old man with dysphagia with solid intake. A, Axial chest CT image shows
tumoral encasement of the esophagus and a moderate amount of bilateral pleural effusion. This finding is confirmed
with, B, a T2-weighted fat-saturated axial MR image, whereas, C, an axial DW image with a b value of 1000 sec/mm2
demonstrates the restrictive lesion around the distal part of the esophagus, as well as hyperintense spots (arrows) on
the right pleura that are suggestive of MPD. C, D, E, F, Increasing the b value in the axial DW images allows the
hyperintense spots (arrows on C, E, F), probably reflecting tumoral tissue, to become more visible. G, Pleuroscopic
image illustrates the tapiocalike pleural lesions. H, H-E staining shows invasive proliferation of polygonal cells with
large eosinophilic cytoplasm, suggestive of malignant pleural tumor. I, Epithelial membrane antigen staining shows a
diffuse, strong positivity. (Original magnification, 3200.)
identical transverse plane, and both independent and coregistered images were available for readout, including CT-based
attenuation-corrected images and nonattenuation-corrected images. Neither respiratory gating nor breath-hold modes were used.
MR images were acquired with a 3-T whole-body system (Achieva; Philips Healthcare, Best, the Neth- erlands) with the
manufacturer’s 16-channel phased-array torso coil (Sense XL Torso; Philips Healthcare) for signal reception. The MR imaging
protocol consisted of nonenhanced
n
T2-weighted single-shot turbo spin-
imaging factor, 43; sensitivity encod- echo (repetition time msec/echo time
ing parallel imaging factor, two; short msec, 828/70; field of view, 302 3 375
tau inversion recovery fat suppression mm; matrix, 187 3 288; and fat sup-
with an inversion time of 260 msec; pression by means of spectral selec-
and number of signals acquired, two) tion attenuated inversion recovery, or
for an imaging time of 12 minutes 19 SPAIR) and DW imaging sequences.
seconds during free breathing. Diffu- DW imaging was performed by us-
sion sensitization was performed with ing a spin-echo echo-planar imaging
b values of 0, 50, 100, 500, 750, and sequence (6481/60; number of trans-
1000 sec/mm2. verse sections, 38; field of view, 420 3 323 mm; section thickness,
5 mm;
Image Interpretation and matrix, 104 3 80, yielding a voxel
CT, PET/CT, and MR images were resolution of 4.0 3 4.0 3 5.0 mm; in-
evaluated separately, with observers tersection gap, 0.7 mm; echo-planar
blinded to all information regarding
Figure 3
Figure 3: Data obtained in a 52-year-old man with recurrent pain in the left side of his chest after left extrapleural
pneumonectomy for MPM. A, B, Axial PET/CT images obtained after extrapleural pneumonectomy indicate difficult
differentiation of the FDG-avid left thoracic cage lesion (recurrence vs postsurgical status). After axial MR imaging
(D), including DW imaging, transthoracic CT-guided biopsy was performed; position- ing is shown on a fused DW
image/CT image (E). Histopathologic findings were used to confirm epithelioid MPM, with positive H-E staining (C)
and prekeratin staining (F); at original magnification (312.5), a pointillistic growth pattern is patent (obvious).
image results of the other modality
were not interpreted because absence
the other modality so we could
assess and histopathologic results. CT im-
of these signs does not allow the clini-
interobserver variability. ages were
assessed by observer 1
cian to rule out disease (2). (W.D.W., a radiologist with 28, 12,
Observer 2 (J.C., a radiologist
Histopathologic Analysis and 3
years of experience in thorax
with 32, 6, and 12 years of experience
Three thoracic surgeons (P.N.,
P.D.L., CT, PET/CT, and MR imaging, respec-
in thorax CT, PET/CT, and MR imag-
and D.V.R., each with more than
12 tively) for the presence or absence of
ing, respectively) assessed the MR
years of experience) performed all
sur- two radiologic signs. First, maximal
images visually by examining pleural
gical procedures. The resected
tissues thickness of mediastinal pleura (in
hyperintense areas on the images ac-
were fixed in a 10% formalin
solution, millimeters) was measured, avoiding
quired by using a b value of 1000 sec/
embedded in paraffin, and stained
with possible adenopathies; this maximal
mm2. When multiple (minimum of
H-E, complemented by
immunohisto- thickness then was categorized as ei-
two) (Fig 1) hyperintense areas visible
chemical staining (1). One
pathologist ther absent (thickness  1 mm) or
by using a b value of 1000 were pre-
(E.V., with 27 years of experience)
ex- present (thickness . 1 mm). Second,
sent in the pleura but were not identi-
amined all sections with light
micros- the involved hemithorax volume loss
fiable as such with lower b values (Fig
copy (magnification range of 312
to due to fibrotic changes was evaluated.
2), it was described as pleural poin-
3400). Using the updated
classification This shrinkage was assessed visually
tillism, and the presence or absence
of the International Mesothelioma
In- in comparison with the nonaffected
of this visual marker was evaluated;
terest Group of the 2004 World
Health hemithorax on a binary scale (present
these results were later correlated
Organization, he coded the
histopath- or absent), with visual assessment of
with the histopathologic analysis re-
ologic results (22). The distribution
of lung volume and interpretation of the
sults. The fat-suppressed T2-weighted
the three examined diagnostic
markers intercostal spaces of both hemithora-
MR images were used to correlate the
(mediastinal thickening, shrinking
ces as evaluating elements. The other
locations of the lesions on the DW
lung, and pleural pointillism)
accord- pleura signs, such as irregularity and
images. After 3 months, each chest
ing to the histopathologic diagnosis
was nodularity of the pleural contour,
radiologist assessed the images from
evaluated.
n
Figure 4
Figure 4: Data obtained in a 70-year-old woman with shrinkage of the right hemithorax after left-sided mastectomy 10
years previously. A, B, Axial PET/CT images show circumferential pleural thickening on the right side with lung
volume loss. This finding was confirmed at axial MR imaging (D), and clear hyperintense points (arrows on E) were
visible at DW imaging. These were confirmed histologically as MPM by means of H-E staining (C) and cytokeratin 5.6
staining (F). (Original magnification, 312.)
Statistical Analysis Statistical analysis was performed by using a software package (Analyse-it, version 2.12; Analyse-it,
Leeds, England). Sensitivity, specificity, PPV, negative predictive value (NPV), and accuracy were calculated for each of the
examined parameters (mediastinal pleural thickness, lung shrinkage, and pleural pointillism) in correlation with histopathologic
findings; 95% confidence intervals obtained by using the Wilson score method are provided. The diagnostic accuracies of the
different parameters examined were compared by using two-tailed McNemar tests, with Bonferroni correction for multiple
testing. Interobserver agreement was evaluated by using the k test, with P values calculated according to the Fleiss method. A P
value less than .05 was considered to indicate a significant difference.
Results
All CT and MR examinations were com- pleted successfully, and histopathologic
n
verification was available for each
0–50 mm. Subdividing the mediastinal patient. Of this cohort, 67 (67%) of
pleural thickness into two groups, namely 100 received a diagnosis of MPD: 57
absent (thickness  1 mm) or present patients had mesothelioma, of which
(thickness . 1 mm) pleural thickening, 46 were epithelioid, six were sarco-
led to 78 patients with a correct diagno- matoid, and three were biphasic, and
sis (sensitivity of 81% [54 of 67], spec- there were two patients with desmo-
ificity of 73% [24 of 33], PPV of 86% plastic pleural disease (1,11,23). Ten
[54 of 63], NPV of 65% [24 of 37], and patients had metastatic diseases—for
accuracy of 78% [78 of 100]). The pres- example, adenocarcinoma, squamous
ence of circumferential pleural thickening lung carcinoma, invasive thymoma,
leading to shrinking lung correctly helped and epithelioid malignant peripheral
in the prediction of pleural disease in 66 nerve sheath tumor. The remaining 33
patients (sensitivity of 60% [40 of 67], (33%) of 100 patients had benign tu-
specificity of 79% [26 of 33], PPV of 85% mors or alterations and inflammatory
[40 of 47], NPV of 49% [26 of 53], and disorders, such as a solitary fibrous tu-
accuracy of 66% [66 of 100]). However, mor, pleural plaques, talc pleurodesis,
using the occurrence of pleural pointil- or pleuritis.
lism as a diagnostic marker resulted in All patients had some form of pleu-
88 correct diagnoses (sensitivity of 93% ral thickening. Examined CT features
[62 of 67], specificity of 79% [26 of 33], suggestive of malignancy were the
PPV of 90% [62 of 69], NPV of 84% [26 thickness of the mediastinal pleural in-
of 31], and accuracy of 88% [88 of 100]). volvement, as well as circumferential
The diagnostic accuracies and confidence pleural thickening leading to apparent
intervals are summarized in Table 1, and shrinking of the lung (Fig 4).
the distribution of the histopathologic di- When we examined the mediastinal
agnosis versus the three examined diag- pleural thickness, we found a range of
nostic markers is given in Table 2.
Table 1
Diagnostic Accuracies and 95% Confidence Intervals of the Three Examined Visual Signs
Mediastinal Thickening Shrinking Lung Pleural Pointillism
Measure
Percentage* 95% Confidence Interval (%) Percentage* 95% Confidence Interval (%) Percentage* 95% Confidence
Interval (%)
Sensitivity 80.6 (54/67) 69.6, 88.3 59.7 (40/67) 47.7, 70.6 92.5 (62/67) 83.7, 96.8 Specificity 72.7 (24/33) 55.8, 84.9
78.8 (26/33) 62.2, 89.3 78.8 (26/33) 62.2, 89.3 PPV 85.7 (54/63) 75.0, 92.3 85.1 (40/47) 72.3, 92.6 89.9 (62/69) 80.5,
95.0 NPV 64.9 (24/37) 48.8, 78.2 49.1 (26/53) 36.1, 62.1 83.9 (26/31) 67.4, 92.9 Accuracy 78.0 (78/100) 68.9, 85.0
66.0 (66/100) 56.3, 74.5 88.0 (88/100) 80.2, 93.0
* Numbers in parentheses were used to calculate the percentages; percentages were rounded.
Table 2
of 60% for pleural malignancy were
Distribution of Histopathologic Diagnosis versus the Presence of the Three Examined Visual Signs
achieved by using CT parameters.
Leung et al (2) and Scott et al (25) described contraction of the affected Diagnosis Mediastinal Thickening Shrinking Lung
Pleural Pointillism
hemithorax (ie, reduced size of the
MPM 82.5 (47/57) Metastasis 70.0 (7/10) Benign 25.0 (5/20) Inflammation 30.8 (4/13) 66.7 (38/57) 20.0 (2/10) 20.0
(4/20) 23.1 (3/13) 96.5 (55/57) 70.0 (7/10) 25.0 (5/20) 15.4 (2/13)
hemithorax involved) with narrowed intercostal spaces and elevation of the ipsilateral hemidiaphragm, possibly associated with
ipsilateral mediastinal shift, as a frequently occurring Note.—Data are percentages; numbers in parentheses were used to
calculate the percentages, which were rounded.
phenomenon in patients with MPM. Kawashima and Libshitz (7) also described this volume loss of the involved Although
McNemar test results
apparent lung shrinkage due to cir-
hemithorax as a CT feature of
MPM, showed a significant difference after
cumferential fibrotic changes (accu-
which occurred in 42% of their co-
Bonferroni correction between the ac-
racy, 66%). We used the term pleural
hort. Sahin et al (6) reported
volume curacy of lung shrinkage compared with
pointillism to describe the presence of
contraction in 73%, and Hierholzer
et the presence of pleural pointillism (P ,
multiple hyperintense spots at high-b-
al (16) used the term shrinking
lung .001), the differences between medias-
value DW imaging because it is visually
for this phenomenon. However, it
also tinal thickening and lung shrinkage (P =
reminiscent of the Postimpressionistic
is observed in patients with
systemic .13) and between mediastinal thicken-
painting technique known as Pointil-
sclerosis, rounded atelectasis,
systemic ing and pleural pointillism (P = .23) did
lism (24).
lupus erythematosus, and primary
not reach significance. The k values for
In the last decade, chest CT has
Sjögren syndrome (7), as well as in
interobserver agreement between both
become the standard imaging method
patients with chronic empyema and
readers were 0.71, 0.48, and 0.53 for
for diagnosis of MPD. The diagnosis
hemothorax. In the patient
population mediastinal thickening, lung shrinkage,
is favored by the presence of parietal
in our study, shrinking lung
showed and pleural pointillism, respectively,
pleural thickening greater than 1 mm,
sensitivity and specificity of 60%
and all P , .001 according to the Fleiss
circumferential pleural thickening,
79%, respectively, and a PPV of
85%. method.
nodular pleural thickening, and medi-
There are also other signs hinting at astinal pleural thickening. In a study
the diagnosis of MPM, such as direct
Discussion
by Leung and coworkers (2), sensitiv-
extension of the lesion into vascular ities of these findings were 47%, 54%,
structures and mediastinal organs
in- In this study, we compared visual as-
38%, and 70%, and specificities of
cluding the heart, esophagus,
trachea, sessments of different imaging pa-
these findings were 94%, 100%, 96%,
and aorta. rameters that could be
used to char-
and 88%, respectively. The visual as-
PET/CT has become routine
clin- acterize primary MPD in a cohort
sessment of the mediastinal pleural
ical practice for assessing stage
(de- of patients who were suspected of
thickening in our study has a slightly
tecting N3 and M1 disease) and
tumor having MPM. We found a good ac-
higher sensitivity but a lower specific-
progression in mesothelioma (26).
Gill curacy of 88% for pleural pointillism
ity (81% and 73%, respectively). In a
et al (11) found sensitivity,
specificity, and lower accuracies for mediastinal
study by Luo et al (17), overall sen-
and accuracy of FDG imaging for
diag- pleural thickness (accuracy, 78%) and
sitivity of 90% and overall specificity
nosis of MPM of 97%, 80%, and 94%,
n
respectively, compared with 83%, 80%, and 82% for diagnostic CT. They mentioned false-positive findings only in patients
treated with talc pleurodesis. Other research groups (12,13) reported benign inflammatory pleuritis, benign asbestos-related
plaques, para- pneumonic effusions, uremic pleuritis, and tuberculous pleuritis as causes for false-positive findings.
False-negative findings due to mild, or lack of, tracer uptake were reported in patients with mesothelioma of the epithelial
subtype and slow-growing fibrous tumors such as low-grade lymphoma or prostate metastasis (17,27).
Currently, the use of MR imaging to detect MPD is increasing because of the high soft-tissue contrast, intrinsic flow
sensitivity, and absence of ioniz- ing radiation (15). With MR imaging, the combination of morphologic and functional imaging
sequences has been reported to have high sensitivity and specificity in detecting pleural malignancy (19). By using a combined
ap- proach of DW imaging and dynamic contrast-enhanced MR imaging, Cool- en et al (19) reached a sensitivity of 71%, a
specificity of 94%, and an accuracy of 93% for diagnosis of MPD. The fast and easy visual assessment of pleural pointillism in
the current study had an only slightly lower accuracy of 88%.
A definitive diagnosis of MPM normally requires histologic sampling with H-E staining and often additional histochemical
stains. In addition, a correlation between multimodality imaging and surgical investigations usu- ally is required. Results from a
2005 report showed that extensive surgery combined with chemotherapy and radiation therapy (trimodality treatment) can
prolong survival in selected patients with early-stage disease (4). This finding emphasizes the need for accurate staging
procedures at diagnosis. In that respect, pleural pointillism has a number of advantages with clinical relevance. First,
pointillism already occurs early in the stages of MPD de- velopment, probably representing small clusters of malignancy that,
because of partial volume and movement effects in
n
the background of high-mobility pleural fluid, do not yet lead to the low apparent diffusion coefficient values indic- ative of
malignancy. Second, because pleural pointillism is a straightforward and easy visual assessment of a single set of images without
any required cal- culations, the diagnostic throughput is high. Third, the pleural pointillism locations can be mapped easily and
used as an aid to perform biopsy sampling of the most appropriate areas, which is important because biopsy sampling can lead to
tumor seeding along the track (reported in up to 22% of MPM patients) and postprocedural pneumotho- rax rates as high as
9.5% (3). Finally, pleural pointillism can help to define the extent of malignancy better without exhausting biopsy sampling of all
possibly malignant regions.
Limitations of this study are the relatively small number of patients included because of the relative rarity of the condition.
Also, because only patients who were suspected of having MPM were included, the results might be biased toward this group
composi- tion. We expect, therefore, that pleural pointillism will not be as specific as reported in this article when used in a
more general patient population. How- ever, we still would advocate that the presence of pointillism should alert the investigator
because the importance of pleural pointillism might be greatest when clinical symptoms are still absent or nonspecific. Also,
although interobserver agreement was acceptable, a relatively low k value was found for the DW imaging pointillism
assessment, which was probably due to a lower level of experience in visual DW image inter- pretations of the radiologist
performing the second DW image reading. How- ever, the reproducibility was still similar to that of the evaluations of the other
examined parameters in this study.
In summary, visual assessment of pleural pointillism on high-b-value DW images seems to be a reasonably accurate tool for
diagnosing MPD. Pleural pointillism might be used to provide guidance for biopsy or thoracoscopic evaluation and eventually
could help obviate invasive procedures, thereby
minimizing patient discomfort. Further larger studies are necessary to validate the clinical applicability and specificity of pleural
pointillism.
Disclosures of Conflicts of Interest: J.C. disclosed no relevant relationships. F.D.K. disclosed no relevant relationships. P.N.
disclosed no relevant relationships. W.D.W. disclosed no relevant relationships. C.D. disclosed no relevant relationships. J.
Vansteenkiste disclosed no relevant relationships. A.D. disclosed no relevant relationships. I.R. disclosed no relevant
relationships. E.V. disclosed no relevant relationships. P.D.L. disclosed no relevant relationships. D.V.R. disclosed no relevant
relationships. K.N. disclosed no relevant relationships. S.D. disclosed no relevant relationships. J. Verschakelen disclosed no
relevant relationships.
References
1. Husain AN, Colby TV, Ordóñez NG, et al. Guidelines for pathologic diagnosis of malignant mesothelioma: a consensus
state- ment from the International Mesotheli- oma Interest Group. Arch Pathol Lab Med 2009;133(8):1317–1331.
2. Leung AN, Müller NL, Miller RR. CT in differential diagnosis of diffuse pleural disease. AJR Am J Roentgenol
1990;154(3):487–492.
3. Wang ZJ, Reddy GP, Gotway MB, et al. Malignant pleural mesothelioma: evaluation with CT, MR imaging, and PET.
Radio- Graphics 2004;24(1):105–119.
4. Benamore RE, O’Doherty MJ, Entwisle JJ. Use of imaging in the management of malignant pleural mesothelioma. Clin
Radiol 2005;60(12):1237–1247.
5. Traill ZC, Davies RJ, Gleeson FV. Thoracic computed tomography in patients with suspected malignant pleural effusions.
Clin Ra- diol 2001;56(3):193–196.
6. Sahin AA, Cöplü L, Selçuk ZT, et al. Malig- nant pleural mesothelioma caused by envi- ronmental exposure to asbestos or
erionite in rural Turkey: CT findings in 84 patients. AJR Am J Roentgenol 1993;161(3):533–537.
7. Kawashima A, Libshitz HI. Malignant pleural mesothelioma: CT manifestations in 50 cases. AJR Am J Roentgenol
1990;155(5):965–969.
8. Beyer T, Townsend DW, Brun T, et al. A combined PET/CT scanner for clinical on- cology. J Nucl Med
2000;41(8):1369–1379.
9. Erasmus JJ, Truong MT, Smythe WR, et al. Integrated computed tomography-positron emission tomography in patients with
po- tentially resectable malignant pleural mesothelioma: staging implications. J Thorac Cardiovasc Surg
2005;129(6):1364–1370.
10. Bénard F, Sterman D, Smith RJ, Kaiser LR,
17. Luo L, Hierholzer J, Bittner RC, Chen Albelda SM, Alavi A. Metabolic imaging
of
J, Huang L. Magnetic resonance imag- malignant pleural mesothelioma with fluo-
ing in distinguishing malignant from be- rodeoxyglucose positron emission
tomogra-
nign pleural disease. Chin Med J (Engl) phy. Chest 1998;114(3):713–722.
2001;114(6):645–649.
11. Gill RR, Gerbaudo VH, Jacobson FL, et al.
18. Luna A, Sánchez-Gonzalez J, Caro P. Diffusion- MR imaging of benign and
malignant pleu-
weighted imaging of the chest. Magn Reson ral disease. Magn Reson Imaging
Clin N Am
Imaging Clin N Am 2011;19(1):69–94. 2008;16(2):319–339, x.
19. Coolen J, De Keyzer F, Nafteux P, et al. Ma- 12. Duysinx B, Nguyen D, Louis
R, et al. Eval-
lignant pleural disease: diagnosis by using uation of pleural disease with
18-fluorode-
diffusion-weighted and dynamic contrast- oxyglucose positron emission
tomography
enhanced MR imaging—initial experience. imaging. Chest 2004;125(2):489–493.
Radiology 2012;263(3):884–892.
13. Kramer H, Pieterman RM, Slebos DJ, et al. PET for the evaluation of pleural thickening observed on CT. J Nucl Med
2004;45(6): 995–998.
20. Gill RR, Umeoka S, Mamata H, et al. Dif- fusion-weighted MRI of malignant pleural mesothelioma: preliminary assessment
of apparent diffusion coefficient in his- 14. Jaruskova M, Belohlavek O. Role of FDG-
tologic subtypes. AJR Am J Roentgenol PET and PET/CT in the diagnosis of pro-
2010;195(2):W125–W130. longed febrile states. Eur J Nucl Med Mol Imaging
2006;33(8):913–918.
21. Rusch VW, Piantadosi S, Holmes EC. The role of extrapleural pneumonectomy in ma- 15. Fujimoto K. Usefulness of
contrast-enhanced
lignant pleural mesothelioma: a Lung Can- magnetic resonance imaging for
evaluating
cer Study Group trial. J Thorac Cardiovasc solitary pulmonary nodules. Cancer
Imaging
Surg 1991;102(1):1–9. 2008;8:36–44.
22. Edge SB, Byrd DR, Compton CC, Fritz AG, 16. Hierholzer J, Luo L, Bittner
RC, et al. MRI
Greene FL, Trotti A. Pleural mesothelioma. and CT in the differential diagnosis of
pleu-
In: Edge SB, Byrd DR, Compton CC, Fritz ral disease. Chest
2000;118(3):604–609.
AG, Greene FL, Trotti A, eds. AJCC can-
n cer staging manual. 7th ed. New York, NY: Springer, 2007; 271–277.
23. Attanoos RL, Gibbs AR. Morphologic variants and their mimics. In: Attanoos RL, Allen TC, eds. Advances in surgical
pathology: mesothelioma. Philadelphia, Pa: Lippincott Williams & Wilkins, 2014; 67–90.
24. Sanna A. Pointillism. In: Impressionism. Florence, Italy: Scala Group, 2011; 441– 496.
25. Scott IR, Müller NL, Miller RR, Evans KG, Nelems B. Resectable stage III lung cancer: CT, surgical, and pathologic
correlation. Ra- diology 1988;166(1 pt 1):75–79.
26. Yi CA, Jeon TY, Lee KS, et al. 3-T MRI: usefulness for evaluating primary lung cancer and small nodules in lobes not
contain- ing primary tumors. AJR Am J Roentgenol 2007;189(2):386–392.
27. Pass HI. Malignant pleural mesothelioma: surgical roles and novel therapies. Clin Lung Cancer 2001;3(2):102–117.

Ga Ush Di Ambil Statiskinya p4

Загружено:

Сведения о документе

Авторское право

Доступные форматы

Поделиться этим документом

Поделиться или встроить документ

Параметры публикации

Этот документ был вам полезен?

Это неприемлемый материал?

Авторское право:

Доступные форматы

Ga Ush Di Ambil Statiskinya p4

Загружено:

Авторское право:

Доступные форматы

576 radiology.rsna.

Malignant Pleural Mesothelioma: Visual

Вам также может понравиться