Ancillary Diagnostic Investigations in Malignant Pleural Mesothelioma

Abstract

For a number of patients presenting with an undiagnosed pleural effusion, frailty, medical co-morbidity or personal choice may preclude the use of pleural biopsy, the gold standard investigation for diagnosis of malignant pleural mesothelioma (MPM). In this review article, we outline the most recent evidence on ancillary diagnostic tests which may be used to support a diagnosis of MPM where histological samples cannot be obtained or where results are non-diagnostic. Immunocytochemical markers, molecular techniques, diagnostic biomarkers and imaging techniques are discussed. No adjunctive test has a sensitivity and specificity profile to support use in isolation; however, correlation of pleural fluid cytology with relevant radiology and supplementary biomarkers can enable an MDT-consensus clinico-radiological-cytological diagnosis to be made where further invasive tests are not possible or not appropriate. Diagnostic challenges surrounding non-epithelioid MPM are recognised, and there is a critical need for reliable and non-invasive investigative tools in this population.

Keywords: biomarkers; malignant pleural mesothelioma; pleural effusion.

Figure 1

A suggested diagnostic approach where distinction of malignant from benign mesothelial proliferation is unclear on initial fluid cytology. BAP1 loss and p16 deletion support the diagnosis of MPM. MPM, malignant pleural mesothelioma; ICC, immunocytochemistry; FISH, fluorescence in-situ hybridization; BAP1, BRCA 1-associated protein.