Mesothelioma information

The chest X-ray typically shows basal homogeneous pacifications on one side due to pleural fluid and sometimes there is evidence of pleural thickening extending upwards around the lung edge. With more advanced disease, ovulated pleural shadowing may appear and, as the tumor progresses and encases the lung, there may be gradual loss of volume on the affected side. Calcified pleural plaques may be present indicating previous asbestos exposure.
CT scanning is very useful in evaluating a patient with suspected Mesothelioma. The appearances may be very characteristic, with an extensive area of pleural tumor encasing the lung and often with an associated pleural effusion.
Although the chest X-ray and CT appearances can strongly suggest the diagnosis of Mesothelioma, it is important to attempt to confirm the diagnosis histologicaly.
Pleural aspiration and biopsy.
A patient suspected of having Mesothelioma will usually have a significant pleural effusion at presentation. The first investigation after a chest X-ray should therefore be pleural aspiration. Pleural aspiration is performed simply under local anesthesia. If there is doubt about the size or location of the pleural fluid, a brief ultrasound examination of the chest may help localize the best site for aspiration.
The fluid obtained is typically a blood-stained exudates. Unfortunately, cytological examination confirms the diagnosis in fewer than 50% of cases. This is partly because it can be difficult to distinguish between reactive mesothelial cells and malignant cells and even if malignant cells are seen, it may be difficult to decide whether they come from a primary or secondary pleural tumor.
If pleural aspiration does not give the diagnosis pleural biopsy, using an Abraham needle, should be carried out. The diagnostic yield is probably no greater than 60% but it may give a more positive diagnosis than cytology. Cutting-needle or incision biopsy of a pleural mass identified on CT scan or of a palpable chest-wall tumor gives the best chance of a definite diagnosis.
Following pleural aspiration or biopsy up to a third of patients will develop tumor seeding down the needle track. Radiotherapy may be helpful in preventing this problem.

Thoracoscopy

If a clear diagnosis is not obtained by pleural aspiration and biopsy, thoracoscopy should be considered. With the advent of flexible fiber optic thoracoscopes, it is possible to carry this out under sedation and local anesthesia rather than putting the patient through a general anesthetic. It may be possible to biopsy pleural nodules and masses under direct vision. Patients should not be subjected to thoracotomy unless there is a real possibility of a successful resection.
Any patient with a persistent undiagnosed pleural effusion, particularly if there is a history of asbestos exposure should have a thoracoscopy to establish the diagnosis. This may be the only way of increasing the number of patients diagnosed early in the course of their illness.

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