Management of malignant pleural mesothelioma - part 1: epidemiology, diagnosis, and staging : Consensus of the Austrian Mesothelioma Interest Group (AMIG)

Abstract

Malignant pleural mesothelioma is a rare malignant disease that in the majority of cases is associated with asbestos exposure. The incidence in Europe is about 20 per million inhabitants and it is increasing worldwide. Initial symptoms are shortness of breath, pleural effusion, cough, and chest pain. The typical growth pattern is along the pleural surface; however, infiltration of the lung and/or mediastinal and chest wall structures can occur in a more advanced stage. Ultimately, distant metastases outside the chest can result. Several histological subtypes of pleural mesothelioma exist, which must be differentiated from either benign diseases or metastases in the pleural space by other tumor entities. This differential diagnosis can be very difficult and a large panel of immunohistochemical markers is required to establish the exact diagnosis. The standard procedure for confirming the disease and obtaining sufficient tissue for the diagnosis is videothoracoscopy. Full thickness biopsies are required, while transthoracic needle puncture of pleural fluid or tissue is considered to be insufficient for a cytological diagnosis. Complete and detailed staging is mandatory for categorization of the disease as well as for therapeutic decision making.

Keywords: Diagnosis; Epidemiology; Malignant pleural mesothelioma; Pathology; Staging.

Fig. 1

Incidence of MPM in comparison to Austria [25]

Fig. 2

Computer tomography of patient with malignant pleural mesothelioma showing circular involvement of the voscera and parietal pleura, pericardium and mediastinum. Pulmonary window (left) and mediastinal window (right)

Fig. 3

Video-assisted thoracoscopic view of MPM mainly on the parietal pleura (a, b), forceps biopsy (c), and talc pleurodesis (d)

Fig. 4

Proposed staging algorithm for MPM patients in Austria

Fig. 5

Examples of malignant pleural mesothelioma (MPM): epithelioid MPM a), biphasic MPM (b), and sarcomatoid MPM (c). (Kindly provided by Dr. Luka Brcic, Department of Pathology, Medical University Graz)

Fig. 6

FDG PET-CT images: malignant pleural mesothelioma of the right pleural cavity (various slides of PET/CT fusion imaging). Varoius slides of CT/PET fusion imaging showing pleural tumor apical right (top left), involving the visceral and parietal pleura in the pleura costodiaphragmatic area (bottom left and right) and the pericardium (top right)