Malignant pleural mesothelioma: an update on investigation, diagnosis and treatment

Abstract

Malignant pleural mesothelioma is an aggressive malignancy of the pleural surface, predominantly caused by prior asbestos exposure. There is a global epidemic of malignant pleural mesothelioma underway, and incidence rates are predicted to peak in the next few years.This article summarises the epidemiology and pathogenesis of malignant pleural mesothelioma, before describing some key factors in the patient experience and outlining common symptoms. Diagnostic approaches are reviewed, including imaging techniques and the role of various biomarkers. Treatment options are summarised, including the importance of palliative care and methods of controlling pleural effusions. The evidence for chemotherapy, radiotherapy and surgery is reviewed, both in the palliative setting and in the context of trimodality treatment. An algorithm for managing malignant pleural effusion in malignant pleural mesothelioma patients is presented. Finally new treatment developments and novel therapeutic approaches are summarised.

FIGURE 1

Ultrasound demonstrating large echoic effusion (A) above a flattened diaphragm (B) with extensive thick, irregular nodularity arising from the diaphragm (C) and visceral pleural (D). This is highly suspicious for malignancy, most likely malignant pleural mesothelioma.

FIGURE 2

FDG (18-fluoro-deoxy-glucose)-positron emission tomography showing malignant pleural mesothelioma. A: an area of high FDG uptake (maximum standardised uptake value of 13.4) in the left lateral pleura beneath the third rib. B: a right paratracheal lymph node with maximum standardised uptake value of 4.6.

FIGURE 3

Flowchart demonstrating the decision making process for investigating and managing pleural effusions in malignant pleural mesothelioma. IPC: indwelling pleural catheter; CXR: chest radiograph.

FIGURE 4

Talc poudrage seen at thoracoscopy. A: parietal pleura with ribs visible beneath and a fine layer of talc covering most of its surface. B: malignant-looking nodule on the parietal pleura. C: collapsed lung with talc covering its surface. D: talc collecting in the para-spinal gutter.