Clinical diagnosis of malignant pleural mesothelioma

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.

Keywords: Pleural mesothelioma; clinical diagnosis; malignant pleural mesothelioma (MPM).

Figure 1

Poster anterior CXR follow-up images of progressive malignant pleural mesothelioma (MPM) in a 61-year-old female. (A) Baseline unilateral (left side) pleural effusion; (B) after 3 months, more diffuse pleural thickening and pleural masses; (C) after 5 months, further ipsilateral volume loss of the left hemithorax with elevation of the ipsilateral hemidiaphragm, ipsilateral mediastinal shift, and narrowing of the intercostal spaces; (D) after 8 months, contralateral spread of disease. CXR, chest radiography.

Figure 2

Whole-body ¹⁸F-FDG PET/CT. Coronal and Sagittal fusion imaging at middle and right side. Transverse reconstruction axis, at left side, has been reported as CT alone, at left top, and as fusion PET/CT imaging below: (A) MPM left unilateral side involvement; (B) severe ¹⁸F-FDG uptake of MPM pertinence at left side, with clear contralateral MPM involvement. MPM, malignant pleural mesothelioma.

Figure 3

Trans-diaphragmatic extension in a 62-year-old man with MPM and peritoneal carcinomatosis. (A) Axial contrast enhanced well-collimated multidetector CT (MDCT); (B) sagittal multiplanar MDCT reconstruction images at level of left hemithorax showing nodular pleural thickening in the left hemidiaphragm (arrows) and a left pleural effusion (*). There is complete encasement of left hemidiaphragm with loss of fat plane between diaphragm and spleen (arrowheads) suggestive of transdiaphragmatic extension; (C) MDCT image shows a thick omental thickening in the left anterior abdomen (arrowheads) and ascites (*) due to intraperitoneal neoplastic seeding; (D) axial fused PET/CT image at the level of superior abdomen shows FDG-avid nodular thickening in the left sub diaphragmatic region (arrows).

Figure 4

Staging for malignant pleural mesothelioma (40,41).