History and Physical Examination

Despite the banning or reduction of asbestos since the 1960s, the incidence of mesothelioma continues to increase because patients develop mesothelioma 20-40 years after asbestos exposure. The long latency period adds to the complexities of early diagnosis and treatment of the condition.

History

The patient’s occupational history is important, and family members with exposure to asbestos should also be evaluated.

Dyspnea and nonpleuritic chest wall pain are the most common presenting symptoms of malignant mesothelioma, with at least 1 of these occurring in 60-90% of patients. Chest discomfort, pleuritic pain, easy fatigability, fever, sweats, and weight loss are the other common accompanying symptoms.

Patients may also be asymptomatic, with evidence of a pleural effusion noted incidentally on physical examination or by chest radiograph.

Metastatic disease is uncommon at presentation; contralateral pleural abnormalities are usually secondary to asbestos-related pleural disease rather than to metastatic disease.

Physical examination

In patients with malignant mesothelioma, physical findings of pleural effusion are usually noted upon percussion and auscultation.

Differential Diagnoses

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Media Gallery

Positron emission tomography (PET) scan in a male patient with known mesothelioma. Although PET scanning is not standard for the evaluation of mesothelioma, this image illustrates the extent of the disease into the mediastinum and peritoneum.
Chest radiograph of a 58-year-old patient with mesothelioma and shortness of breath. This image reveals diffuse, left-sided pleural thickening, a pleural effusion, and ipsilateral volume loss.
Computed tomography scan of a 58-year-old patient with mesothelioma and shortness of breath. This image shows the extensive pleural thickening that is characteristic of mesothelioma, effusion, and reduction in the volume of the affected hemithorax.
Computed tomography scan of the chest. This image demonstrates mesothelioma that extends into the chest wall. Note the concentric left pleural thickening, pleural effusion, reduction in volume of the left hemithorax, and the tumor nodules within the chest wall.
Magnetic resonance imaging (MRI) scan in a 72-year-old Veterans Administration patient with left-sided mesothelioma. Note that the MRI scan well delineates the soft tissues and, in particular, the thoracoabdominal interface at the diaphragm.
Computed tomography (CT) scan in a male Veterans Administration patient with a history of asbestos exposure and an enlarging abdominal girth. This upper CT scan slice reveals the calcified pleural plaques along the diaphragmatic surface that are associated with asbestos exposure. Ascites is seen lateral to the liver. Aspiration of the ascitic fluid demonstrated mesothelioma.
The soft-tissue window setting of this chest computed tomography (CT) scan shows the envelope-like mass along the pleural surface surrounding the lung. This was a mesothelioma.
The classic description of malignant pleural mesothelioma is a thickening in the pleural space with encasement of the lung by a rindlike visceral pleura. These gross specimens are from an autopsy lung case with diffuse thickening of the pleura causing compression of the underlying lung tissue.
This histologic section stained with hematoxylin and eosin shows papillary structures on the right and a transition to a more solid pattern on the left.
A solid pattern of mesothelioma on the right of this histologic section transitions to a spindle cell morphology on the left of the image in this predominantly sarcomatoid malignant mesothelioma.
Well differentiated papillary mesothelioma is characterized with a single layer of bland cuboidal cells lining fibrovascular cores, as demonstrated in this image.
Immunohistochemistry helps to demonstrate that the atypical mesothelial cells in this reactive proliferation are in fact in one roughly linear layer, an important criterion supporting a benign process.

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Author

Winston W Tan, MD, FACP Associate Professor of Medicine, Mayo Medical School; Consultant and Person-in-Charge of Genitourinary Oncology-Medical Oncology, Division of Hematology/Oncology, Department of Internal Medicine, Mayo Clinic Jacksonville; Vice Chairman, Division of Hematology/Oncology Education, Chair, Cancer Survivorship Program, Associate Chair, Department of Medicine Faculty Development, Mayo Clinic Florida; Vice President, Florida Society of Clinical Oncology

Winston W Tan, MD, FACP is a member of the following medical societies: American College of Physicians, American Society of Clinical Oncology, American Society of Hematology, Philippine Medical Association, Texas Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Nagla Abdel Karim, MD, PhD Director of Early Therapeutics, Inova Schar Cancer Institute; Professor of Medicine, University of Virginia School of Medicine

Nagla Abdel Karim, MD, PhD is a member of the following medical societies: American Medical Association, American Society of Clinical Oncology, Egyptian American Medical Association, Egyptian Cancer Society, International Association for the Study of Lung Cancer

Disclosure: Nothing to disclose.

Additional Contributors

Alain C Borczuk, MD Professor of Clinical Pathology, Vice Chairman of Anatomic Pathology, Columbia University College of Physicians and Surgeons; Visiting Assistant Professor, Albert Einstein College of Medicine; Attending Pathologist, New York Presbyterian Hospital

Alain C Borczuk, MD is a member of the following medical societies: College of American Pathologists, United States and Canadian Academy of Pathology, Pulmonary Pathology Society, New York Pathological Society

Disclosure: Nothing to disclose.

Acknowledgements

Benjamin Movsas, MD Vice-Chairman, Department of Radiation Oncology, Fox Chase Cancer Center

Benjamin Movsas, MD is a member of the following medical societies: American College of Radiology, American Radium Society, and American Society for Therapeutic Radiology and Oncology

Disclosure: Nothing to disclose.

Michael Perry, MD, MS, MACP Nellie B Smith Chair of Oncology Emeritus, Director, Division of Hematology and Medical Oncology, Deputy Director, Ellis Fischel Cancer Center, University of Missouri-Columbia School of Medicine

Michael Perry, MD, MS, MACP is a member of the following medical societies: Alpha Omega Alpha, American Association for Cancer Research, American College of Physicians, American College of Physicians-American Society of Internal Medicine, American Medical Association, American Society of Clinical Oncology, American Society of Hematology, International Association for the Study of Lung Cancer, and Missouri State Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment