Moderne radiologische Ansätze zu Diagnostik und Staging des pleuralen Mesothelioms

Zusammenfassung

Das Pleuramesotheliom (PM) ist ein hochaggressiver Tumor, der in engem Zusammenhang mit einer früheren Asbestexposition steht. Symptome treten i. d. R. erst 20–50 Jahre nach Exposition auf. Je nach histologischem Subtyp des PM variiert die Prognose, die mediane Überlebenszeit liegt jedoch bei nur 12–18 Monaten. Die Bildgebung spielt eine zentrale Rolle im Management von PM-Patienten, insbesondere bei der Beurteilung der Operabilität und des Therapieansprechens. Jedoch stellt das PM eine besondere Herausforderung für die Radiologie dar, da es selten ist, eine komplexe Morphologie aufweist und zu einer gleichzeitigen Invasion mehrerer Gewebsschichten neigt. Die kontrastmittelgestützte Computertomografie (CT) stellt die zentrale bildgebende Methode in der Diagnose, präoperativen Planung und Therapieüberwachung des PM dar. Idealerweise wird eine CT sowohl des Thorax als auch des Abdomens durchgeführt, um den gesamten pleuralen Raum abzubilden. Tumordicke und -volumen, die mittels CT bestimmt werden, sind wichtige prognostische Faktoren für das Überleben von PM-Patienten. Zusätzlich bietet die PET/CT, die radioaktiv markierte Fluordesoxyglukose (¹⁸F-FDG) verwendet, wertvolle Einblicke in den Tumorstoffwechsel. Da das PM typischerweise metabolisch aktiv ist, eignet sich die PET/CT besonders gut zur Detektion kleinerer Läsionen, okkulter Metastasen und zur Beurteilung morphologisch unklarer Läsionen. Die Magnetresonanztomografie (MRT) bietet hingegen deutliche Vorteile gegenüber der CT aufgrund ihres überlegenen Weichteilkontrasts, insbesondere bei der Darstellung des Tumorausmaßes und der Infiltration benachbarter Strukturen. Dynamische Kontrastmitteluntersuchungen, Diffusionsbildgebung und 4D-Sequenzen liefern weitere wertvolle Zusatzinformationen. Orientierend an den „Best Practices“ des Experten-Panels „International Mesothelioma Interest Group“ (iMig), geben wir einen Überblick über die gängigen bildgebenden Verfahren, darunter das konventionelle Röntgen, die CT, MRT und PET/CT. Außerdem gehen wir auf das Staging anhand der TNM-Klassifikation (Tumor, Nodus, Metastasen) ein, was die lokale Invasion des Tumors (T), die Lymphknotenbeteiligung (N) und das Vorliegen von Metastasen (M) bewertet. Außerdem zeigen wir Beispiele für die Beurteilung des Therapieansprechens und erläutern neuere Entwicklungen in der bildgebenden Diagnostik.

Abstract

Pleural mesothelioma (PM) is a highly aggressive tumour, mainly associated with prior asbestos exposure. Symptoms typically do not manifest until 20 to 50 years after exposure. Depending on the histological subtype of PM, the prognosis varies, though the median survival time is only 12–18 months. Imaging plays a central role in the management of PM patients, particularly in assessing operability and treatment response. However, PM presents a unique challenge for radiology due to its rarity, complex morphology, and tendency to invade multiple tissue layers simultaneously. Contrast-enhanced computed tomography (CT) is the central imaging modality in the diagnosis, preoperative planning and therapy monitoring of pleural mesothelioma (PM). Ideally, CT should include both the thorax and abdomen to capture the entire pleural space. Tumour thickness and volume, as determined by CT, are important prognostic factors for patient survival in PM. In addition, PET/CT, using radioactively labelled fluorodeoxyglucose (¹⁸F-FDG), offers additional valuable insights into tumour metabolism. Since PM is typically metabolically active, PET/CT is particularly effective in detecting smaller lesions, occult metastases, and assessing morphologically ambiguous lesions. Magnetic resonance imaging (MRI), on the other hand, offers distinct advantages over CT, due to its superior soft tissue contrast, particularly in visualizing tumour extent and infiltration of adjacent structures. Dynamic contrast-enhanced imaging, diffusion-weighted imaging, and 4D sequences provide valuable additional information. On the basis of the “Best Practices” of the expert panel from the International Mesothelioma Interest Group (iMig), we provide an overview of the common imaging modalities, including conventional X-ray, CT, MRI, and PET/CT. Additionally, we discuss staging based on the TNM classification (Tumour, Node, Metastasis), which evaluates the local invasion of the tumour (T), lymph node involvement (N), and the presence of metastases (M). We also present examples of assessing treatment response and highlight recent developments in diagnostic imaging.

Schlüsselwörter

Pleuramesotheliom - CT - MRT - PET/CT - Radiomics - TNM

Keywords

pleural mesothelioma - CT - MRI - PET/CT - radiomics - TNM

Publication History

Received: 24 September 2024

Accepted after revision: 02 April 2025

Article published online:
19 May 2025

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