Clinical diagnosis of malignant pleural mesothelioma

Our plain-English summary of Clinical diagnosis of malignant pleural mesothelioma, by A. Bianco, T. Valente, M.L. De Rimini, et al (Journal of Thoracic Disease, 2018).

The study

• Authors: A. Bianco, T. Valente, M.L. De Rimini, G. Sica, A. Fiorelli
• Journal: Journal of Thoracic Disease
• Published: 2018;10(Suppl 2):S253-S261
• Type of article: Review
• Cited by: 38 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Malignant pleural mesothelioma (MPM) is a tumour which, despite progress in diagnostic procedures and biomolecular research, has poor prognosis. Symptoms reflect extension of disease and include shortness of breath and chest pain. Unexplained pleural effusion and pleural pain in patients exposed to asbestos should raise the suspicion of MPM. MPM diagnosis requires imaging procedures X-ray and computed tomography (CT) scans; magnetic resonance imaging (MRI) better defines the extension of the tumor while PET scanning provides additional information on metabolic activity, metastases, and response to treatment. Thoracoscopic biopsy remains the most appropriate procedure for definitive diagnosis of mesothelioma. Multimodality treatment including surgery, chemotherapy and radiotherapy has been associated with a better survival in selected patients. Clinical translational research including new approaches targeting immune-checkpoints is opening new horizons which may lead to personalised treatments.

In plain English

This article is a review, not a new study. The authors described what is known about how malignant pleural mesothelioma (MPM), a cancer of the lining around the lungs, develops, how it shows itself, and how it is diagnosed. Drawing on other publications, they described asbestos as the major cause of MPM, with the disease appearing up to 40 years after exposure. They also listed other suspected factors, including prior radiation and other mineral fibers such as erionite. They described common symptoms, including breathlessness, chest pain, weight loss and fatigue. They reviewed chest X-ray, ultrasound, CT, MRI and PET-CT scans, blood markers and biopsy, quoting figures from other sources. For example, an earlier review reported that CT had a sensitivity of 68% and a specificity of 78% for pleural cancer. They also set out the staging system mainly in use. The authors concluded that unexplained pleural effusion (fluid around the lung) and pleural pain in people exposed to asbestos should raise suspicion of MPM. They also concluded that thoracoscopic biopsy remains the most appropriate procedure for a definitive diagnosis.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Narrative review of the pathogenesis, clinical features and diagnostic procedures of malignant pleural mesothelioma; no new patient data were collected
• Who was studied: No study population; the review discusses published literature on patients with malignant pleural mesothelioma. Figures illustrate individual cases, including a 61-year-old woman and a 62-year-old man.
• Exposure: Asbestos, in general terms, described as the major carcinogen associated with MPM. Other suspected risk factors mentioned are prior radiation exposure, other mineral fibers such as erionite, synthetic materials (ceramics, nanoparticles), familial forms and simian virus 40 (SV40), whose role the authors call controversial.
• Main results:
  • Citing other sources, the review states that onset of MPM is delayed up to 40 years after fibre exposure, which makes screening challenging
  • Citing other sources, the review states that median survival ranges from 7 months with supportive care to 12 months with chemotherapy
  • Citing other sources, the review states that most MPM patients present with breathlessness, chest pain, weight loss and fatigue
  • The review states that the small number of patients without symptoms at diagnosis appear to survive longer, probably because they are diagnosed earlier
  • Citing other sources, the review states that certain thoracic ultrasound findings (pleural masses, pleural thickening over 1 cm, nodular pleural thickening, diaphragmatic nodularity) have a specificity above 95% for malignancy, but a sensitivity of only 40%
  • Citing an earlier review, the authors report that CT had a sensitivity of 68% and a specificity of 78% for pleural malignancy. They state that CT cannot tell MPM apart from cancer that has spread to the pleura from elsewhere.
  • The review states that on PET-CT a standardised uptake value threshold of 2 can reliably separate benign from malignant disease. It also states that PET cannot tell MPM apart from metastatic pleural cancer, and that it can give false negative results (early or slow-growing MPM) and false positive results (inflammatory conditions).
  • The review states that serum mesothelin-related protein (SMRP) has been found to be high in 84% of patients. It does not say which study or group this figure comes from.
  • The review states that cytology samples may be inconclusive, and that large biopsies with immunohistochemistry are generally needed to distinguish mesothelioma from other tumors such as adenocarcinoma and to define its subtype
  • The authors concluded that thoracoscopic biopsy remains the most appropriate procedure for definitive diagnosis
• The authors' conclusion: The authors concluded that unexplained pleural effusion and pleural pain in patients with asbestos exposure should raise the suspicion of MPM

Topics

Medical terms in this study, explained in our Lexicon: Pleural Mesothelioma, Prognosis, Pleural Effusion, Thoracoscopic Biopsy, Mesothelioma, Chemotherapy.

Related studies

• Vascular endothelial growth factor in pleural fluid for differential diagnosis of benign and malignant origin and its clinical applications — A. Fiorelli, G. Vicidomini, et al. (2011)
• Malignant pleural mesothelioma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up — P. Baas, D. Fennell, et al. (2015)
• Peritoneal mesothelioma: PSOGI/EURACAN clinical practice guidelines for diagnosis, treatment and follow-up — S. Kusamura, V. Kepenekian, et al. (2021)
• Malignant pleural mesothelioma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up — R.A. Stahel, W. Weder, et al. (2010)
• Malignant Mesothelioma Biomarkers: From Discovery to Use in Clinical Practice for Diagnosis, Monitoring, Screening, and Treatment — J. Creaney, B.W.S. Robinson (2017)
• BAP1 Immunostain and CDKN2A (p16) FISH Analysis: Clinical Applicability for the Diagnosis of Malignant Mesothelioma in Effusions — A.E. Walts, K. Hiroshima, et al. (2016)

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