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A 70-year-old white man with past medical history of hypertension (HTN) and chronic obstructive pulmonary disease (COPD) presents with a persistent cough for the last 2 months. He has a 60 pack-year smoking history. He worked for 20 years as a coal miner. Chest x-ray reveals a moderate size right-sided pleural effusion. Chest computed tomography (CT) confirms a loculated pleural effusion and pleural-based nodules. On thoracentesis, 500 mL of fluid is removed, and analysis reveals exudative effusion without evidence of malignant cells on cytology. What should be the next step in management of this patient?

Learning Objectives

  1. What are the risk factors associated with malignant pleural mesothelioma?

  2. What is the diagnostic modality of choice for malignant pleural mesothelioma?

  3. What is the ideal treatment approach for resectable non-metastatic malignant pleural mesothelioma?

  4. What is the first line of therapy for metastatic malignant pleural mesothelioma?


Malignancies involving mesothelial cells that normally line the body cavities, including the pleura, peritoneum, pericardium, and testis, are known as malignant mesothelioma. Pleural involvement is the most common (85%), followed by peritoneum (15%) and pericardium and tunica vaginalis (1%).

Mesothelioma is a rare malignancy with 2,500 new cases diagnosed annually in the United States. It commonly develops in the fifth to seventh decade of life. The male-to-female ratio is 4:1.


Asbestos, particularly the types of amphibole asbestos known as crocidolite and amosite asbestos, is the principal carcinogen implicated in the pathogenesis of malignant pleural mesothelioma.1 A substantial proportion of patients with malignant pleural mesothelioma are exposed to asbestos in asbestos mills, mines, shipping yards, paper mills, auto parts (asbestos brake lining), railroad repair, and insulation.


Family members of workers exposed to asbestos can also be at risk of exposure if asbestos becomes embedded in the workers’ clothing.

Other associations include exposure to radiotherapy (RT) and erionite (mineral found in sand gravel).

Smoking does not increase the increase of mesothelioma, but together with asbestos exposure does significantly increase the risk of lung carcinoma (adenocarcinoma).


Dyspnea and non-pleuritic chest wall pain are the most common presenting symptoms of malignant mesothelioma. Chest discomfort, pleuritic pain, easy fatigability, fever, sweats, and weight loss are the other common accompanying symptoms. Metastatic disease is uncommon at presentation.


Contralateral pleural abnormalities are usually secondary to asbestos-related pleural disease rather than to metastatic disease.


Biochemical Tests

Several biomarkers are selectively elevated in patients with mesothelioma, including soluble mesothelin-related peptides, fibulin-3, and osteopontin. Of these biomarkers, the circulating serum mesothelin receptor protein level has been reported to be elevated in 84% of patients with malignant mesothelioma and in 2% of patients with lung ...

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