Electricians in the past were frequently exposed to asbestos and this is a crucial question to ask in the clinical history.
Pleural biopsy will confirm the diagnosis. This has traditionally been carried out blind, i.e. without image guidance. The procedure is carried out with the patient seated comfortably and leaning forward with the posterior of the chest wall exposed. Using the chest X-ray for localisation, under sterile conditions, the superficial tissues are infiltrated with local anaesthetic at a suitable rib interspace. A biopsy needle is inserted adjacent to the superior rib border (to avoid the neurovascular bundle) and the pleural biopsy taken. Ultrasound can be used to identify pleural thickening, and thereby guide biopsy and target potentially pathological areas.
Malignant mesothelioma is often related to previous asbestos exposure with a lag period of up to 30 years or more. It usually presents as a multilobulated pleural mass encircling the lung. It involves the mediastinal pleural reflections and often extends into the lung fissures or out to the chest wall, particularly, along a biopsy track. Pericardial involvement or diaphragmatic invasion can occur. Pleural effusions are common and these may be loculated. Other manifestations of asbestos exposure include pleural calcification, folded lung (see Fig. 1.77) (which may be mistaken for a malignant mass) and asbestosis.
Causes of pleural malignancy
■ Bronchial adenocarcinoma.
■ Breast carcinoma.
■ Malignant thymoma.
■ Subpleural lymphoma.
■ Malignant mesothelioma.
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