Statement on malignant mesothelioma in the United Kingdom
Authors: None British Thoracic Society Standards of Care Committee
Journal: Thorax (2001)

+ Mesothelioma should be considered in any patient with either pleural fluid or pleural thickening, especially if chest pain is present.+ Mesothelioma may occasionally present with persistent unexplained chest pain and a normal chest radiograph.+ Symptomatic metastatic disease is unusual at presentation.+ The disease is inexorably progressive except in the few patients who have undergone curative surgery.PROGNOSIS + Median survival is poor, varying from 8 to 14 months in diVerent studies, similar to other types of lung cancer.+ Epithelioid tumours have a better than average prognosis.DIAGNOSIS + The importance of a detailed occupational history cannot be overemphasised.+ Any patient in whom mesothelioma is suspected should be promptly referred to a respiratory physician for further assessment.+ Pathological confirmation of the diagnosis is recommended, unless the patient is frail or has extremely advanced disease.+ Negative pleural biopsy and cytology results do not exclude mesothelioma and should lead to further investigation.+ CT scanning plays a key role in the diagnosis of mesothelioma.Diagnostic imaging + CT scanning should be performed on all patients with undiagnosed pleural exudates.+ Pleural plaques are indicators of asbestos exposure but are absent in many proven cases of mesothelioma attributable to asbestos fibre.+ Demonstration of chest wall invasion by either CT scanning or MRI is highly suggestive of malignant rather than benign pleural disease.Pathological diagnosis + Pleural fluid cytology and histology of blind biopsy specimens have low diagnostic yield for mesothelioma but are important initial steps in diVerential diagnosis.+ Ultrasound and CT guided biopsy and thoracoscopic and surgical biopsy techniques should be used to increase the likelihood of accurate diagnosis.+ Pathologists should attempt to specify the histological type of mesothelioma.+ A selection of special stains should be used to help diVerentiation of mesothelioma and pleural adenocarcinoma.TREATMENT STRATEGY + Staging is essential for correct selection of patients for surgery.+ Staging provides important prognostic information.+ Staging should be undertaken before clinical trials.RADICAL SURGERY + There are no randomised control trials to establish the role of radical surgery.+ Radical surgery should only be considered when there is a positive diagnosis of epithelioid mesothelioma.+ Surgery should only be performed in centres where there is an interest and experience in performing extrapleuropneumonectomies.+ The limited evidence available has reported surgical results only as part of a multimodality treatment strategy.MANAGEMENT OF PLEURAL EFFUSIONS + Talc pleurodesis is probably the treatment of choice for the control of pleural fluid.+ VATS pleurectomy is an eVective treatment to control pleural fluid in mesothelioma and is much safer than open pleurectomy and decortication.+ The value of pleuroperitoneal shunts remains uncertain.RADIOTHERAPY + Prophylactic radiotherapy reduces chest wall implantation following invasive procedures.+ Palliative radiotherapy provides pain relief in about half of all patients.+ Palpable masses respond to radiotherapy in about half of all patients.+ Breathlessness and superior vena caval obstruction rarely respond to radiotherapy.CHEMOTHERAPY + All patients with mesothelioma should have the opportunity to discuss the pros and cons of chemotherapy with either an oncologist or respiratory specialist.+ There are no published randomised trials comparing either survival or symptom control in patients treated with chemotherapy or best supportive care.