4th Edition

Chapter 27: The builder who could not climb his ladder

A 64-year-old builder was sent by his wife to see his GP because he was getting so short of breath that he could no longer climb up his ladder. He also had a productive cough with a 40 pack year history of smoking.

His GP organized a chest X-ray.

  • 1. What does it show?

    Correct answer:
    Pleural thickening and haziness of the left lung field.

A thoracic CT scan followed.

  • 2. What did the CT show?

    Correct answer:
    Thickening of the mediastinal, costal and diaphragmatic pleura, as well as the oblique fissure. These appearances are attributable to widespread pleural mesothelioma.

A video-assisted thoracoscopic (VATS) biopsy confirmed epithelial mesothelioma.

  • 3. What post-operative prophylactic treatment is necessary?

    Correct answer:
    Post-operative prophylactic single fraction radiotherapy of the biopsy track was performed to reduce the risk of tumour seeding.

As he has extensive pleural involvement, he is not a candidate for potentially curative approaches and instead is offered palliative chemotherapy with cisplatin and pemetrexed. The median survival that his oncologist quoted was 6-9 months, but as he was a builder, he doubled the quote.

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