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Treatment
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Once the diagnosis has been established, management consists of treatment of the primary neoplasm and any pulmonary complications Surgical resection of a solitary pulmonary nodule is often prudent in the patient with known current or previous extrapulmonary cancer Local resection of one or more pulmonary metastases is feasible in a few carefully selected patients with various sarcomas and carcinomas (breast, testis, colon, kidney, and head and neck) Surgical resection should be considered only if the primary tumor is under control, if the patient is a good surgical risk, if all of the metastatic tumor can be resected, if nonsurgical approaches are not available, and if there are no metastases elsewhere in the body Relative contraindications to resection of pulmonary metastases include (1) malignant melanoma primary, (2) requirement for pneumonectomy, (3) pleural involvement, and (4) simultaneous appearance of two or more metastases The overall 5-year survival rate in secondary lung cancer treated
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A Symptoms and Signs
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The mean age at onset of symptoms of malignant pleural mesothelioma is about 60 years Symptoms include the insidious onset of shortness of breath, nonpleuritic chest pain, and weight loss Physical findings include dullness to percussion, diminished breath sounds and, in some cases, digital clubbing
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B Laboratory Findings
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Pleural fluid is exudative and often hemorrhagic VATS biopsy is usually necessary to obtain an adequate specimen for
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Weight loss common Endoscopy with biopsy establishes diagnosis
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histologic diagnosis; even then, distinction from benign inflammatory conditions and from metastatic adenocarcinoma may be difficult The histologic variants of malignant pleural mesothelioma are epithelial and fibrous (sarcomatous) Special stains and electron microscopy may be needed to confirm the diagnosis
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General Considerations
Esophageal cancer usually develops in persons between 50 and 70 years of age The overall ratio of men to women is 3:1 There are two histologic types: squamous cell carcinoma and adenocarcinoma In the United States, squamous cell cancer is much more common in blacks than in whites Chronic alcohol and tobacco use are strongly associated with an increased risk of squamous cell carcinoma The risk of squamous cell cancer is also increased in patients with tylosis (a rare disease transmitted by autosomal dominant inheritance and manifested by hyperkeratosis of the palms and soles), achalasia, caustic-induced esophageal stricture, and other head and neck cancers Squamous cell cancer has a high incidence in certain regions of China and Southeast Asia Half of all cases occur in the distal third of the esophagus Adenocarcinoma is more common in whites It is increasing dramatically in incidence and now is as common as squamous carcinoma The majority of adenocarcinomas develop as a complication of Barrett s metaplasia due to chronic gastroesophageal reflux Thus, most adenocarcinomas arise in the distal third of the esophagus Obesity also is strongly associated with adenocarcinoma, even after controlling for gastroesophageal reflux; however, no causal relationship has been convincingly shown
C Imaging
Radiographic abnormalities consist of nodular, irregular, unilateral pleural thickening and varying degrees of unilateral pleural effusion There may be scoliosis toward the side of the lesion CT scan helps demonstrate the extent of pleural involvement
Complications
Malignant pleural mesothelioma progresses rapidly as the tumor spreads along the pleural surface to involve the pericardium, mediastinum, and contralateral pleura The tumor may eventually extend beyond the thorax to involve abdominal lymph nodes and organs Progressive pain and dyspnea are characteristic Local invasion of thoracic structures may cause superior vena cava syndrome, hoarseness, Horner s syndrome, and dysphagia Paraneoplastic syndromes associated with mesothelioma include thrombocytosis, hemolytic anemia, disseminated intravascular coagulopathy, and migratory thrombophlebitis
Treatment
Treatment with surgery, radiotherapy, chemotherapy, and a combination of methods has been attempted but is generally unsuccessful Some surgeons believe that extrapleural pneumonectomy is the preferred surgical approach for patients with early stage disease Drainage of pleural effusions, pleurodesis, radiation therapy, and even surgical resection may offer palliative benefit in some patients
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