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Malignant Pleural Mesothelioma: Evaluation with CT, MR Imaging, and PET¹

¹ From the Department of Radiology, Box 0628, University of California, San Francisco, 505 Parnassus Ave, San Francisco, CA 94143. Presented as an education exhibit at the 2002 RSNA scientific assembly. Received March 10, 2003; revision requested April 10 and received May 23; accepted May 27. All authors have no financial relationships to disclose. Address correspondence to G.P.R. (e-mail: gautham.reddy@radiology.ucsf.edu).

View larger version (142K): [in a new window]   Figure 1a.  Pleural effusion in a 70-year-old man with a history of asbestos exposure and known left-sided MPM. Axial contrast material-enhanced CT scans obtained at different levels show unilateral pleural effusion (P) with extensive calcified pleural plaques (arrows).

View larger version (177K): [in a new window]   Figure 1b.  Pleural effusion in a 70-year-old man with a history of asbestos exposure and known left-sided MPM. Axial contrast material-enhanced CT scans obtained at different levels show unilateral pleural effusion (P) with extensive calcified pleural plaques (arrows).

View larger version (139K): [in a new window]   Figure 2.  Nodular pleural thickening in a 55-year-old man with MPM. Axial nonenhanced CT scan shows nodular pleural thickening in the right hemithorax (arrows).

View larger version (147K): [in a new window]   Figure 3.  Pleural thickening in a 51-year-old man with MPM. Axial contrast-enhanced CT scan shows circumferential and nodular left-sided pleural thickening (arrows). The tumor encases the contracted left hemithorax, having a rindlike appearance.

View larger version (151K): [in a new window]   Figure 4.  Pleural thickening in a 63-year-old man with MPM who had undergone an Eloesser flap procedure for mesothelioma. Axial contrast-enhanced CT scan shows circumferential right-sided pleural thickening (arrowheads). Note also the large chest wall defect (arrow) from the Eloesser flap procedure.

View larger version (127K): [in a new window]   Figure 5.  Interlobar fissure involvement in an 82-year-old man with MPM and a history of pleurodesis. Axial nonenhanced CT scan shows right-sided pleural thickening and a pleural mass that extends into the right major fissure (arrows).

View larger version (139K): [in a new window]   Figure 6a.  Calcified pleural mass in a 55-year-old woman with MPM. Axial nonenhanced CT scans obtained at different levels show multiple calcified subpleural and pleura-based masses (arrow). The masses represent either plaques that have been engulfed by the primary tumor or calcified MPM.

View larger version (170K): [in a new window]   Figure 6b.  Calcified pleural mass in a 55-year-old woman with MPM. Axial nonenhanced CT scans obtained at different levels show multiple calcified subpleural and pleura-based masses (arrow). The masses represent either plaques that have been engulfed by the primary tumor or calcified MPM.

View larger version (158K): [in a new window]   Figure 7.  Hemithoracic contraction in a 68-year-old man with a history of MPM. Axial contrast-enhanced CT scan shows a severely contracted left hemithorax and ipsilateral mediastinal shift.

View larger version (153K): [in a new window]   Figure 8.  Chest wall invasion in a 65-year-old man with a history of MPM. Axial nonenhanced CT scan shows a large left-sided pleural mass with involvement of the chest wall (*). Note the extension of the tumor into the extrapleural fat plane.

View larger version (174K): [in a new window]   Figure 9.  Chest wall invasion in a 60-year-old man with a history of asbestos exposure and MPM. Axial contrast-enhanced CT scan shows diffuse chest wall involvement by the tumor (arrows). Obliteration of extrapleural fat planes and invasion of intercostal muscles are also seen. Such diffuse chest wall involvement is classified as T4 disease (unresectable).

View larger version (138K): [in a new window]   Figure 10a.  Mediastinal invasion in a 65-year-old woman with MPM. Axial contrast-enhanced CT scans show nodular tumor extension into the mediastinum, with a soft-tissue mass behind the trachea (* in a), esophagus (arrowheads in b), and left atrium (arrows in c). Such diffuse mediastinal involvement is classified as T4 disease (unresectable).

View larger version (64K): [in a new window]   Figure 10b.  Mediastinal invasion in a 65-year-old woman with MPM. Axial contrast-enhanced CT scans show nodular tumor extension into the mediastinum, with a soft-tissue mass behind the trachea (* in a), esophagus (arrowheads in b), and left atrium (arrows in c). Such diffuse mediastinal involvement is classified as T4 disease (unresectable).

View larger version (135K): [in a new window]   Figure 10c.  Mediastinal invasion in a 65-year-old woman with MPM. Axial contrast-enhanced CT scans show nodular tumor extension into the mediastinum, with a soft-tissue mass behind the trachea (* in a), esophagus (arrowheads in b), and left atrium (arrows in c). Such diffuse mediastinal involvement is classified as T4 disease (unresectable).

View larger version (162K): [in a new window]   Figure 11a.  Transdiaphragmatic extension in a 65-year-old woman with a history of MPM. Axial contrast-enhanced CT scans obtained at different levels show a soft-tissue mass that encases the diaphragm (* in a) and liver (arrows in b). Transdiaphragmatic extension makes this a T4 tumor (unresectable).

View larger version (174K): [in a new window]   Figure 11b.  Transdiaphragmatic extension in a 65-year-old woman with a history of MPM. Axial contrast-enhanced CT scans obtained at different levels show a soft-tissue mass that encases the diaphragm (* in a) and liver (arrows in b). Transdiaphragmatic extension makes this a T4 tumor (unresectable).

View larger version (78K): [in a new window]   Figure 12.  Pulmonary metastases in a 68-year-old man with MPM. Axial high-resolution chest CT scan shows extensive septal thickening and perilymphatic nodules (arrows), findings that are consistent with lymphangitic tumor spread. The presence of pulmonary metastases makes this a stage IV tumor (unresectable).

View larger version (98K): [in a new window]   Figure 13.  Pulmonary metastases in a 72-year-old man with MPM. Axial high-resolution chest CT scan shows multiple pulmonary nodules (circled), findings that are consistent with hematogenous tumor spread and represent stage IV disease (unresectable). Note also the right apical pneumothorax (*).

View larger version (115K): [in a new window]   Figure 14a.  Hepatic metastases in a 73-year-old man with a history of MPM. (a) Axial contrast-enhanced chest CT scan shows a nodular right-sided posterior pleural mass with associated calcification (arrow), a finding that is consistent with the patient’s known history of mesothelioma. (b, c) Axial contrast-enhanced abdominal CT scans obtained at different levels show a large, hypovascular liver mass (M) with central necrosis (b) and calcification (arrows in c).

View larger version (188K): [in a new window]   Figure 14b.  Hepatic metastases in a 73-year-old man with a history of MPM. (a) Axial contrast-enhanced chest CT scan shows a nodular right-sided posterior pleural mass with associated calcification (arrow), a finding that is consistent with the patient’s known history of mesothelioma. (b, c) Axial contrast-enhanced abdominal CT scans obtained at different levels show a large, hypovascular liver mass (M) with central necrosis (b) and calcification (arrows in c).

View larger version (175K): [in a new window]   Figure 14c.  Hepatic metastases in a 73-year-old man with a history of MPM. (a) Axial contrast-enhanced chest CT scan shows a nodular right-sided posterior pleural mass with associated calcification (arrow), a finding that is consistent with the patient’s known history of mesothelioma. (b, c) Axial contrast-enhanced abdominal CT scans obtained at different levels show a large, hypovascular liver mass (M) with central necrosis (b) and calcification (arrows in c).

View larger version (146K): [in a new window]   Figure 15a.  Mediastinal lymphadenopathy in a patient with MPM. Axial contrast-enhanced CT scans obtained at different levels show lymphadenopathy in low right paratracheal (a) and left retrobronchial (b) locations (arrows).

View larger version (152K): [in a new window]   Figure 15b.  Mediastinal lymphadenopathy in a patient with MPM. Axial contrast-enhanced CT scans obtained at different levels show lymphadenopathy in low right paratracheal (a) and left retrobronchial (b) locations (arrows).

View larger version (144K): [in a new window]   Figure 16a.  MR imaging evaluation of MPM in a 63-year-old man. (a, b) Coronal (a) and contrast-enhanced fat-saturated (b) T1-weighted MR images show a large, enhancing right apical mass (M) with invasion of the chest wall (arrows in a). An enhancing right major fissure is also seen (arrowheads in b). (c, d) Sagittal T1-weighted (c) and coronal T2-weighted (d) MR images show the mass (M) with involvement of the diaphragmatic pleura (arrows). However, there is no invasion of the diaphragmatic muscle itself, which is visualized as an intact black line above the liver (arrowheads).

View larger version (160K): [in a new window]   Figure 16b.  MR imaging evaluation of MPM in a 63-year-old man. (a, b) Coronal (a) and contrast-enhanced fat-saturated (b) T1-weighted MR images show a large, enhancing right apical mass (M) with invasion of the chest wall (arrows in a). An enhancing right major fissure is also seen (arrowheads in b). (c, d) Sagittal T1-weighted (c) and coronal T2-weighted (d) MR images show the mass (M) with involvement of the diaphragmatic pleura (arrows). However, there is no invasion of the diaphragmatic muscle itself, which is visualized as an intact black line above the liver (arrowheads).

View larger version (155K): [in a new window]   Figure 16c.  MR imaging evaluation of MPM in a 63-year-old man. (a, b) Coronal (a) and contrast-enhanced fat-saturated (b) T1-weighted MR images show a large, enhancing right apical mass (M) with invasion of the chest wall (arrows in a). An enhancing right major fissure is also seen (arrowheads in b). (c, d) Sagittal T1-weighted (c) and coronal T2-weighted (d) MR images show the mass (M) with involvement of the diaphragmatic pleura (arrows). However, there is no invasion of the diaphragmatic muscle itself, which is visualized as an intact black line above the liver (arrowheads).

View larger version (143K): [in a new window]   Figure 16d.  MR imaging evaluation of MPM in a 63-year-old man. (a, b) Coronal (a) and contrast-enhanced fat-saturated (b) T1-weighted MR images show a large, enhancing right apical mass (M) with invasion of the chest wall (arrows in a). An enhancing right major fissure is also seen (arrowheads in b). (c, d) Sagittal T1-weighted (c) and coronal T2-weighted (d) MR images show the mass (M) with involvement of the diaphragmatic pleura (arrows). However, there is no invasion of the diaphragmatic muscle itself, which is visualized as an intact black line above the liver (arrowheads).

View larger version (120K): [in a new window]   Figure 17a.  Preoperative PET evaluation in a 78-year-old man with biopsy-proved MPM. (a) Axial contrast-enhanced CT scan shows circumferential nodular left-sided pleural thickening (arrows). (b, c) Axial (b) and coronal (c) PET scans show diffusely increased FDG uptake in the pleura of the left hemithorax (arrows), a finding that correlates well with the CT finding.

View larger version (137K): [in a new window]   Figure 17b.  Preoperative PET evaluation in a 78-year-old man with biopsy-proved MPM. (a) Axial contrast-enhanced CT scan shows circumferential nodular left-sided pleural thickening (arrows). (b, c) Axial (b) and coronal (c) PET scans show diffusely increased FDG uptake in the pleura of the left hemithorax (arrows), a finding that correlates well with the CT finding.

View larger version (125K): [in a new window]   Figure 17c.  Preoperative PET evaluation in a 78-year-old man with biopsy-proved MPM. (a) Axial contrast-enhanced CT scan shows circumferential nodular left-sided pleural thickening (arrows). (b, c) Axial (b) and coronal (c) PET scans show diffusely increased FDG uptake in the pleura of the left hemithorax (arrows), a finding that correlates well with the CT finding.

View larger version (102K): [in a new window]   Figure 18.  PET evaluation in a 65-year-old woman with MPM. Sagittal PET scan shows increased FDG uptake in the entire left pleural space with involvement of the left major fissure (arrow).

View larger version (78K): [in a new window]   Figure 19.  PET evaluation of metastatic disease in a 73-year-old man with known MPM. Sagittal PET scan shows a single focus of increased FDG uptake in the superficial aspect of the left middle to lower portion of the neck (arrow). Biopsy results confirmed MPM metastases to the skin.

View larger version (142K): [in a new window]   Figure 20a.  PET evaluation of metastatic disease in a 71-year-old man with known MPM. Coronal PET scans obtained at different levels show increased FDG uptake in the left supraclavicular (a) and right mediastinal (b) regions (arrows), a finding that is consistent with nodal metastases. Involvement of contralateral mediastinal lymph nodes or of ipsilateral or contralateral supraclavicular lymph nodes is classified as stage IV disease (unresectable).

View larger version (146K): [in a new window]   Figure 20b.  PET evaluation of metastatic disease in a 71-year-old man with known MPM. Coronal PET scans obtained at different levels show increased FDG uptake in the left supraclavicular (a) and right mediastinal (b) regions (arrows), a finding that is consistent with nodal metastases. Involvement of contralateral mediastinal lymph nodes or of ipsilateral or contralateral supraclavicular lymph nodes is classified as stage IV disease (unresectable).

View larger version (116K): [in a new window]   Figure 21.  PET evaluation of metastatic disease in a 61-year-old woman with known MPM. Axial PET scan shows increased FDG uptake in the left inferolateral chest wall (arrows), a finding that is consistent with tumor invasion.