21st February 2025

Mesothelioma

The malignancy most strongly associated with asbestos exposure is malignant mesothelioma. 

Asbestos exposure also increases the risk of developing other types of lung cancer. The investigation and management of these should be the same as for lung cancer of any other cause (see Lung cancer).

Pathology and risk factors in mesothelioma

Exposure to asbestos is the main risk factor for mesothelioma, and around 80% of patients with mesothelioma have a history of this. The average latency between exposure and development of mesothelioma is 20 to 40 years. 

Around 90% of mesothelioma cases are pleural, though mesothelioma can also develop in the peritoneum (5-10%), pericardium and testes (<1% each).

Presentation and investigation of mesothelioma

The most common symptoms of pleural mesothelioma include chest pain and dyspnoea, as well as constitutional symptoms such as fever and weight loss. Pleural effusions are often present at diagnosis. 

NICE suspected cancer guidelines for mesothelioma are summarised below:

Table 7 NICE guidelines for suspected mesothelioma

Chest X-ray is recommended as the initial screening investigation. Following an X-ray, A CT of the chest and upper abdomen should be offered if there is high clinical suspicion of malignancy. CT signs suggestive of mesothelioma include nodular pleural thickening, hilar or mediastinal lymphadenopathy and invasion into surrounding structures such as the chest wall.

Even following CT, it can be difficult to differentiate benign from malignant pleural disease on imaging alone. If present, pleural effusions should be tapped for cytology. Yield can be low, so tissue biopsy is often required in addition, either by VATS (video-assisted thoracoscopic surgery) or transcutaneous CT-guided biopsy.

A PET scan should be considered to assess for regional or distant spread of disease.

Management of mesothelioma

Mesothelioma has a poor prognosis, with a median survival of 10 to 15 months.

In some cases, surgery with curative intent can be considered, usually combined with chemotherapy or radiotherapy.

In most cases, treatment will be palliative. Surgery, radiotherapy and systemic therapies (including chemotherapy, angiogenesis inhibitors and immunotherapy) can all play a role in palliative management. Platinum chemotherapy (usually cisplatin/carboplatin + pemetrexed) has been the mainstay of systemic treatments.

Pleurodesis and indwelling pleural catheters are useful in managing recurrent effusions.