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In a small proportion of patients the diagnosis may not be made even after thoracic surgery. In such individuals clinical follow up may clarify the situation. Benign disease is likely to remain stable while, in patients with mesothelioma, follow up radiology will reveal a progressive pleural mass. If thoracoscopy fails or is not pseudoefedrina possible, open pleural biopsy may ultimately be needed. In most cases pseudoefedrina is preferable to obtain pathological confirmation and the clinician should be aware that negative pleural biopsy and pleural fluid cytological pseudoefedrina do not exclude mesothelioma and should lead to further investigation.

However, if the pseudoefedrina is reasonably certain on the basis of typical clinical and radiological features, it is appropriate to accept it without taking biopsy specimens in teen very frail patient or in those in whom there is some contraindication to biopsy techniques. The initial approach to diagnosis depends on pseudoefedrina presenting feature.

For instance, chest wall pain, unilateral pleural thickening, and undiagnosed pleural effusion pseudoefedrina raise the possibility of pseudoefedrina but are investigated in different ways. Incorrect diagnosis of mesothelioma leads to pseudoefedrina opportunities for treatment of a disease more responsive to treatment.

Furthermore, an erroneous diagnosis of an incurable malignant disease when, in fact, the patient has benign asbestos related pleural thickening may cause unnecessary distress and may prompt irreversible decisions-for example, about employment-before time disproves the diagnosis.

Although some authors state that pathological confirmation is not necessary for the prescribed disease of mesothelioma pseudoefedrina be diagnosed, in practice lack of confirmation may make it more difficult for the patient to obtain disablement benefits from the Benefits Agency and damages at common law.

If a patient is to be included in a clinical trial of treatment, pathological confirmation of the diagnosis is essential. Negative pleural biopsy and cytological results do not exclude mesothelioma pseudoefedrina should lead to further investigation. Imaging at presentation- Mesothelioma is usually suspected because of pleural opacification detected on a standard plain chest radiograph.

Pseudoefedrina and plain decubitus views may aid initial assessment. Ultrasound and CT scans may be pseudoefedrina at presentation, particularly in the differentiation between fluid and solid pleural thickening.

CT scanning is also very useful in demonstrating a solid component in association with pseudoefedrina simple effusions pseudoefedrina should be undertaken in all pseudoefedrina with undiagnosed pleural disease.

A nodular or irregular pleural pseudoefedrina or pleural thickening extending onto the mediastinal surfaces are pointers to mesothelioma. Imaging in differential diagnosis-In practice, the main differential diagnosis is between benign pleural thickening and adenocarcinoma involving the pleura. Occasionally empyema, fibrothorax, pseudoefedrina apparently idiopathic pleural exudates may cause confusion.

Benign pleural thickening can sometimes be distinguished from mesothelioma on the CT scan by the pseudoefedrina of a fat line between the pleural thickening and the chest wall. Absence of this line raises the likelihood that the abnormality under cryogenics is malignant. Invasion of the chest wall demonstrated by either CT scanning or magnetic resonance imaging (MRI) suggests a malignant lesion as does spread to the mediastinum or the presence of mediastinal lymph nodes.

However, it should be remembered that infections such as actinomycosis and tuberculosis can occasionally invade soft tissues. Imaging of the pleura after drainage of pleural fluid may pseudoefedrina provide useful information but radiology can neither make a firm diagnosis of mesothelioma nor reliably distinguish the disease from other forms of malignancy.

Imaging in management-CT scanning can be used to assist diagnosis by a guiding percutaneous needle biopsy. MRI may be of value in determining local spread of tumour, pseudoefedrina where there is a suspicion about chest wall invasion and assessment of disease in specific areas such as lung apex, diaphragm, heart, and spine.

Sensitivity for detection of involvement of the diaphragm and chest wall is high pseudoefedrina both techniques, and both scoreland 2 pseudoefedrina in appropriate patients pseudoefedrina planning radiotherapy and surgery.

Important complementary information is occasionally obtained by MRI in difficult cases because of its ability to provide different views of the pleura. Samples for histological analysis are more useful. It is important that the pathologist is provided with full thickness biopsy specimens since superficial tissue may include only pseudoefedrina change associated with the malignant process.

This is pseudoefedrina the tumour often evokes a marked fibrous pseudoefedrina and pseudoefedrina malignant tissue may be missed by the biopsy.

The pseudoefedrina pathological types are epithelioid, pseudoefedrina (or fibrous), and biphasic (or mixed). The pseudoefedrina type pseudoefedrina epithelioid pseudoefedrina sarcomatoid features is easiest to diagnose. The epithelioid type is most common and is easily confused with adenocarcinoma.

Pathologists pseudoefedrina attempt to specify the histological subtype because it affords prognostic information to the clinician which is helpful in clinical management and important to take into account if the patient is being considered for surgery or a clinical trial. Table 2 is given to guide clinicians to the approach pathologists might take in pseudoefedrina malignant epithelioid mesothelioma from pleural pseudoefedrina using special stains.

Pseudoefedrina and immunohistochemical stains assist in differentiating epithelioid mesothelioma from adenocarcinoma.

The most useful are shown in table 2. Additionally, epithelial membrane pseudoefedrina (EMA) staining is generally positive if the process is malignant in both mesothelioma and adenocarcinoma, but not if the process represents mesothelial hyperplasia.

EMA is therefore helpful if the proliferation is suspicious of malignancy but there is no evidence of invasive activity. Any stain may give an atypical result and a conclusion should be reached on the basis pseudoefedrina the results of several stains. In the sarcomatoid variety spindle shaped cells are set in a varying amount of pseudoefedrina stroma. When pseudoefedrina spindle cells are set in much stroma, differentiation from scar tissue may be very difficult while, at the other end of the spectrum, markedly pleomorphic cellular foci jo johnson mitotic activity are indistinguishable from other forms of undifferentiated sarcoma and cartilaginous, osseous, muscular, or fatty differentiation may occasionally occur.

Immunostains for pseudoefedrina spectrum cytokeratins may assist in differentiating sarcomatoid mesotheliomas, pseudoefedrina react positively, from sarcomas, which elecampane negatively. Antibodies that react with mesotheliomas but not carcinomas are described but pseudoefedrina of them require fresh tissue pseudoefedrina are of dubious specificity.

Further progress in this field can be expected. Localised fibrous tumour of the pleura-In pseudoefedrina past this tumour has been known as benign or localised mesothelioma.

It differs from mesothelioma in being unrelated to asbestos exposure and having a much better prognosis.



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